Membership Application - MKUH Question Title 1. Title Mr Mrs Ms Miss Doctor Question Title 2. Please complete: First name Surname Email Telephone Address line 1 Address line 2 City / Town County Postcode Question Title 3. Date of birth Please enter your date of birth Date Question Title 4. Gender Male Female Rather not say Question Title 5. Ethnic origin White British White Irish White Other Black or Black British: African Black or Black British: Caribbean Black or Black British: Other Asian or Asian British: Indian Asian or Asian British: Pakastani Asian or Asian British: Bangladeshi Asian or Asian British: Other Mixed: White and Black Caribbean Mixed: White and Black African Mixed: White and Asian Mixed other Chinese Other (please specify) Question Title 6. Contact preference Email Post Telephone Question Title 7. The information you supply will be used to contact you about Milton Keynes University Hospital NHS Foundation Trust membership and other issues relating to the hospital. The data will be stored in accordance with the Data Protection Act and will not be passed onto to other organisations. The Trust is obliged to maintain a public register of its members. This register only gives member's name and which constituency they belong to. No other information information about a member is available publicly. Tick the box if you DO NOT want your name to appear on the public register of members. I agree Done
