Royal Liverpool Children's NHS Trust

If you would like to become a member, please complete this form. Members must be aged seven or over. Please consider if other members of your family would like to join. Contact us for more copies using this form.

Contact details
Surname:
First Name(s):
Title:
Street address:
Town:
County:
Postcode:
Tel Home:
Tel Office:
Tel Mobile:
Email:
Please indicate your preferred mode of contact: Post Email
About you
Sex:
Date Of Birth:
Have you ever been a patient at the Trust? Yes
Are you a parent/ carer of a child who has been a patient at the Trust? Yes
Your constituency
You can only belong to one group: patient, parent/carer or public. If you belong to more than one constituency, you can choose which you would like to be in. 1. A patient is defined as being a patient or former patient aged between 7 and 19 years old. 2. A parent/carer is someone who acts as the patient/former patient’s natural parent, adoptive parent, current foster parent or main carer. The patient/former patient must be under 20 years of age. 3. A member of the public is someone aged 7 and over who lives in England or North Wales.
Your constituency:
Your Childs Name:
Your Childs Date Of Birth:
Your ethnic Group
Our membership must be representative of the communities we serve, so we need to keep track of the ethnic background of our members. Please tick one of these boxes as appropriate:
Ethnic Group:
If you chose Other please state:
Your interests
Which newsletter(s) would you like to receive?	Adult newsletter Children and young people's newsletter
Being regularly consulted about hospital plans/developments
Participating in focus groups
Standing for election as a Governor
Fundraising for Alder Hey’s charity, the Imagine Appeal
Please tick here if you do not wish to be contacted by the Imagine Appeal
What other areas are you interested in?
Your family and friends
If you would like us to send copies of this leaflet for family members or friends, or a membership form for the children and young people’s club, please let us know.
Adult membership form:	Yes ~ If Yes, how many copies
Children’s membership form:	Yes ~ If Yes, how many copies
Our membership values
We are committed to working with others to improve children’s health and wellbeing. We are committed to listening to and valuing children and young people, recognising that they have their own rights and responsibilities. We also work in partnership with our patients’ families. As a provider of healthcare and training and education, a research centre, an employer and a membership organisation, we do not discriminate on the grounds of age, sex, race, ethnic origin, sexuality, belief or disability. We are committed to child protection. All elected or appointed Governors will undergo the required checks to make sure that they are not a danger to children, staff or the integrity of the Trust. In addition, by joining, members accept the right of the Foundation Trust to make any checks on individual members it considers necessary. They will only be made with the member’s knowledge and any information will be used fairly, confidentially and responsibly. Members agree to act in the best interests of the Trust and its patients, to raise their concerns constructively and to act with mutual openness, tolerance and respect to all.
Thank you for taking the time to register. Your details will be held on a confidential database in accordance with the Data Protection Act 1998. NHS Foundation Trusts are required to publish a publicly available register of members. If you do not want your name to appear on the public register please tick this box.

Foundation Trust

Why we are changing

What is a Foundation Trust?

Frequently asked questions

Timetable

What is membership

Consultation documents