Volunteer campaign form - This survey is created by QuestionPro

Please complete the details below and state which areas of patient involvement interests you.

Name

Address including full postcode

Contact telephone numbers (please include landline and mobile number)

Email Address

What is your sex? (Select one option)

Male

Female

Intersex

Prefer not to say

What is your age? (Select one option)

Under 16

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

Prefer not to say

What is your ethnicity? (Select one option)

Asian or Asian British

Bangladeshi

Chinese

Indian

Pakistani

Any other Asian background

Black or Black British

African background

Caribbean

Any other Black background

Mixed

Asian and White

Black African and White

Black Caribbean and White

Any other Mixed or multiple background

White

British, English, Northern Irish, Scottish, Welsh

Irish

Gypsy/ Traveller

Roma

Any other White background

Other

Arab

Polish

Somali

Prefer not to say

Any other ethnicity

Registered GP Surgery including address

Please tick which volunteering opportunities you are interested in below. You can select more than one volunteering opportunity.

If you'd like more detail on each opportunity, visit our volunteering page (opens in new window).

Leicester Leicestershire and Rutland Integrated Care Board

Patient Participation Groups (PPGs)

Online Citizens' Panel

Leicestershire Partnership NHS Trust (LPT)

General volunteering

Patient and Carer Involvement Network

Patient or Carer Lived Experience Partner

The Youth Advisory Board (YAB) (13-21 year olds only)

University of Hospitals Leicester (UHL)

Meet and greet

Buggy Drivers

Ward Support

Secret Garden

Young People Pathway (16-21 year olds only)

Specific areas e.g. Emergency Department, Cardiac rehab/pre-assessment etc.

Healthwatch Leicester and Leicestershire

Enter & View Authorised Representative

Youthwatch

Engagement and events

Healthwatch Rutland

Healthwatch Community Champions

Enter and View Volunteers

E) How did you hear about this campaign? (Select all that apply)

Facebook

Twitter

Instagram

Through the LLR ICB website

Text message from your GP Practice

Your GP website

Email from your GP Practice

A poster

A postcard

Newspaper

Through a friend or a family member

Through a staff communication

Other (please state)

Permission to share

I hereby give my permission for NHS Leicester, Leicestershire and Rutland Integrated Care Board (LLR ICB) to share the personal information I have provided on this form with the organisations that I am interested in volunteering with (the practice that I am a registered patient with; Leicestershire Partnership NHS Trust; University Hospitals of Leicester; Healthwatch Leicester and Leicestershire; Healthwatch Rutland). I understand that LLR ICB may hold the information about me in line with my rights under the Data Protection Act.

Please tick to confirm your agree to share your information; If you do not provide your consent then we will not be able to pass your information to the organisation(s) you are interested in volunteering with.