Patient Participation Group Registration

If you are interested in joining the group please complete the registration form.

Your form will be passed to the Practice Manager and the PPG Chair who will contact you about your application.

Patient Participation Group Registration

Patient Participation Group Registration

If you are human, leave this field blank.

Please select one below: *

Mr

Mrs

Miss

Ms

Dr

Rev

Other

Please specify: *

Full Name: *

Phone Number: *

Home Address:

Postcode:

Email Address: *

Any responses we send will go to this email address.

More about you

Please give us a little background information about yourself.

Ethnic Background: *

White British

White Irish

White and Black Caribbean

White and Black African

White and Asian

Indian

Pakistani

Bangladeshi

Caribbean

African

Chinese

Other

Age group: *

Under 16

17 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

Over 84

Do you have children of your own or care for children? *

Yes

No

How old are they? *

Are you a Carer? *

Yes

No

Have you had any connection with the medical world recently or in the past? *

Yes

No

Have you served on any committees? *

Yes

No

Why are you interested in becoming a PPG member? *

PPG meetings are usually held at 16:30, would this be a problem for you? *

Yes

No

Please provide a name and email address of a referee who may be approached if necessary. *

You are not required to complete a DBS check for this volunteer work.

Full Name in block capitals: *

Signed: *

Date: *