About You
We are committed to building a What geographical area do you Please tell us how you would like membership that reflects the diverse live in? to be involved, you can tick more communities we serve and we would than one box be grateful if you would complete the Crawley Horsham following section. Online surveys Mole Valley Reigate & Date of Birth: Banstead Take an interest in focus groups Becoming a Member of Tandridge D D M M Y Y Y Y Croydon Attend meetings or events Mid Sussex Find out more about becoming Surrey & Sussex I am: Male Female a governor Do you have any special interests Transgender regarding care? Please tick all the following Healthcare NHS Trust Medicine e.g Rehabilitation, which apply Do you consider yourself to have a disability? Accident & Emergency Live within our catchment area
Yes No Prefer not Women’s Health e.g. Maternity, Someone who uses our services to say Gynaecology A carer of someone who uses Ethnicity Children’s Services e.g. Paediatrics our services
White British Black Surgery e.g General Surgery, Volunteer Caribbean Orthopaedics White Irish Other Other Black Outpatients Please state below: Other White background Support services e.g. cleaning, White & Black Indian food, parking, volunteers Caribbean Pakistani White & Black How did you hear about African Bangladeshi our membership? This information will only be used by White & Asian Other Asian At a public Received Surrey and Sussex Healthcare NHS background meeting a leaflet Trust in conjunction with membership Other Mixed Chinese and public involvement, and in Background Face to face Via our accordance to the Data Protection Act Other ethnic recruitment services/ 1998. We are obliged to keep a public Black African group staff register of members, if you do not On our wish to be included on this register website Through the please tick this box Sexual Orientation local press/ Other media Thank you for taking your time to Heterosexual Gay Woman Please state fill in this form and for becoming (Straight) (Lesbian) below: a member.
Bisexual Prefer not Your support is appreciated. to say Gay Man Membership Application Form What is a NHS foundation trust? Members play a key role in our Trust and you will be able to get more involved Return completed form to: by becoming a member. Anyone aged 14 and over can join as long as they are, Freepost (RRGU-LBSY-HCSL) NHS foundation trusts remain firmly part of the NHS, but or have been a patient or carer in the past 5 years, or live in the Trust’s Foundation Trust Office - AD55 they have more freedom from government control, and catchment area, which is made up of the following local council areas: Crawley, East Surrey Hospital instead become more accountable to local communities, Horsham, Mid Sussex, Mole Valley, Reigate & Banstead, Tandridge and Croydon. Redhill patients and staff who are members. By involving the RH1 5RH members and the Council of Governors in deciding how the services are delivered, NHS foundation trusts are able to Name Title deliver services in a way that better meet the user’s needs and preferences Do you have any special information requirements?
Frequently Asked Questions About Us Audio Large print
Can I become a member? Why should I become a member? Surrey and Sussex Healthcare NHS Braille Other Anyone can become a member, so long Membership provides the opportunity Trust was formed on 1st April 1998 Address Please state as they are over 14, and is, or has been for you to have your say in how the following a merger between East below: a patient or carer in the past 5 years; or trust is run and have an active role in Surrey Healthcare NHS and Crawley lives in Mole Valley, Reigate & its future development. Horsham NHS Trusts. We provide a Banstead, Tandridge, Crawley, Mid range of health services at East Sussex, Horsham or Croydon; or is a Members benefits include: Surrey Hospital, in Redhill. In member of staff. • Regular newsletters keeping you up addition, we also provide a range of Postcode to date with what’s happening at East health services including outpatient Surrey Hospital, and in our other and diagnostic services at Dorking GREATER LONDON services, such as fundraising and Catherham Dene Hospitals, 7 events and medical developments. Oxted Health Centre, in Surrey, and at Crawley, Horsham and Queen Telephone (land line or mobile) SURREY 5 KENT 2 3 • Regular members’ health events Victoria Hospitals in West Sussex. Would you like more How many? with consultants and specialists on application forms so your 1 topics, such as care for the elderly and The Trust is a major local employer family and friends can join? WEST SUSSEX 6 EAST children’s health services. with a diverse workforce of 4 SUSSEX around 3,500 providing healthcare Email Contacting members by email is the most cost-effective method of We will send you the forms along with • An opportunity to play an active role services to a growing population communication. If you are willing to receive information by email please provide a freepost addressed envelope to post in member consultations, focus of 535,000. your email address below: the completed forms back to us. groups, and involvement opportunities. 1 Crawley 5 Reigate & If you would like further information Banstead • Access to Health Service Discounts – or more membership forms, see: 2 Mole Valley saving money for you and your family. Patients and carers that live in our 6 Mid Sussex www.surreyandsussex.nhs.uk/ft catchment area are eligible to be 3 Tandridge • Receive a vote for electing your What is your connection to the Trust? public members, and will vote for the 7 Croydon representatives to serve on the Council Or contact the membership office: public governors. Patients and carers 4 Horsham of Governors, and if over 16, you can Are you a member of the that do not live in one of the seven choose to stand for election to the Tel: 01737 768511 Ext 1864 public/patient or carer that lives A member of Trust staff areas we’ve identified as our Council of Governors. inside our catchment area? catchment area, will be eligible to be How much will I need to Email: patient members and will vote for get involved? [email protected] Representing a group/organisation A patient or carer that lives the patient governors. You make the decision about how outside our catchment area much or little you want to be involved. Write: Freepost (RRGU-LBSY-HCSL) I declare I am eligible and would like to become a member of the Trust How much will it cost me? Foundation Trust Office - AD55 Continued over page» Nothing - membership is free East Surrey Hospital Redhill Signed How long will I have to join for? How do I become a member? RH1 5RH You can stop your membership at any Please complete the form (opposite) or time by simply writing to us. apply on line at www.sash.nhs.uk/ft Date