Individual Member Application Form

Healthwatch Steering Group

Individual member application form

Please write clearly or type (this form will be photocopied)

Your first name / Your familyname
Your Address:.
Postcode
Daytime telephone number:
Email address:

1)Are you a Healthwatch Coventry member? (You must be a member of Healthwatch to be on the Steering Group – to be a member you just need to fill out a membership form we can send you one of these or you can join via the Healthwatch website:

YES / NO (not yet)

2)Please say why you would like to be on the Healthwatch Steering Group (Maximum 250 words

3)Please say how your personal qualities, experience and skills meet the person specification for Steering Group member

3a) Your personal qualities
3b) Your experience
3b) Your skills and knowledge (including commitment to learn)

4)Healthwatch Coventry has a sizeable remit therefore each Steering Group member will take the lead on an area of local NHS or social care services; so please say which area you would be willing to take a lead on

We are seeking a balance in the Group so are you willing to pick up a different area? (you don’t need to have any detailed knowledge of these area , but must be willing to learn)

Please rank just your top 3 with 1 being the highest

Ambulance and patient transport services
Community health services (health service provided in community or home setting)
Drug and alcohol services
Hospital services
Learning disability services
Mental health services
Primary care services (GPs, Dentists, Opticians)
Representing Healthwatch on Health & Social Care Scrutiny Board 5 (meets Wed pm)
Adult social care services
Children’s social care services
Other (please say

5) If you are on any user groups, partnership groups or reference groups please give details of the group and your role on it?

Name of group / Your role

Declaration of interests

Do you have any business or personal interests which may be relevant to the work of Healthwatch, which might be or perceived to be a conflict of interest if you were to join the Steering Group? (Failure to disclose information could result in the role being terminated).

Yes / No

If yes please give details

Equal opportunities monitoring

Please complete this section which will be detached from the remainder of the form we receive before the form is passed to the panel.

Do you consider yourself to be disabled? / Yes / No

Please provide any details which would be helpful to us

Are you

Male / Female / Transgender

Please indicate your age

Under 16 / 25-34 / 45-54 / 65-74
16-24 / 35-44 / 55-64 / 74+

Ethnicity

White / Asian or Asian British
British / Indian
Irish / Pakistani
Traveller/Romany / Bangladeshi
Eastern European / Other Asian (please say)
Other White (please say)
Black or Black British
Mixed / Caribbean
White and Black Caribbean / African
White and Black African / Other Black (please say)
White and Asian
Other Mixed (please say) / Chinese or other ethnic group
Chinese
Other ethnic group (Please say)

Declaration

I have read and understand the role description for a Steering Group Member and I wish to put myself forward for the role. To the best of my knowledge the information given on this form is correct. I understand that giving false information will disqualify my application, or if discovered after appointment may be regarded as grounds for termination of the role.

Your signature / Date:

Please return this application form to:

Ruth Light,

Healthwatch Chief Officer,

Healthwatch Coventry,

29 Warwick Road,

Coventry, CV1 2EZ

Or email:

By 5 pm 10 October 2016

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