Expression of interest form

If you would be interested in attending the East Kent NHS transformation engagement event on 18 July 2019 please fill in the form below. We will confirm places by 26 June 2019.

We will be allocating places to ensure diverse representation at the workshop from people across east Kent, so if you would like to be considered we do need answers to all questions.

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* Please confirm that, if offered a space at the workshop, you can attend for the full day on 18 July 2019.

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* Full name

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* Email address

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* Phone number

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* Location (village/town)

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* Postcode

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* Age

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* Sex

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* Ethnicity

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* Employment status

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* Do you have children under 16 years old?

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* Are you an unpaid carer?

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* Do you consider yourself disabled?

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* Would you need any special equipment/support to take part in this workshop?

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* Have you, or someone you care for, used any of the following hospital services in the last year? (please tick all that apply)

  William Harvey Kent and Canterbury Queen Elizabeth the Queen Mother
A&E/urgent care centre
Inpatient stay
Outpatient visit
Maternity unit
Not used any of the above

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* Are you currently a volunteer/member of any patient or public involvement groups or community groups? (e.g. GP patient participation group, hospital trust governor, patient support group etc)

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* If you would be interested in taking part in other similar events in future, please tick the box below.
We will add your email to our mailing list for future events and updates on our work.

Thank you. We will be confirming bookings for the workshop by 26 June 2019 and will send full details of the event to all those who are offered a space.

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