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Healthwatch Gloucestershire Registration Form

Please complete the following form - fields marked with * are a mandatory requirement.
View the guidance notes for this form.


Contact Information

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*


Address

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*



*

Contact Details








Preferred method of contact:*





** We need your permission to be able to text you even if we already have your mobile number. By giving us your mobile number you are agreeing to receive information by text message and understand that the information given will be held and used in accordance with the Data Protection Act 1998 and that permission continues to be granted until confirmed in writing that it is withdrawn.

What areas of health and social care are you interested in?

Please tick all the areas you are interested in (you can tick more than one box):


What areas of health and social care do you have experience in?

Please tick all the areas you have experience in (you can tick more than one box):


How would you like to be involved in Healthwatch activity?

How would you like to be involved in Healthwatch activity? (for active members, please tick):





How can we help you take part in Healthwatch Gloucestershire?

Please tick any special requirements you have (you can tick more than one box):


Agreement

*


Required for representatives only


Please make sure all fields marked with * are completed