Sign up to get involved

Sign up below and we'll keep you up-to-date with occasional email updates.

We just need a few details about what you are interested in hearing about and a bit about you and your background. This helps us understand more about who is joining the conversation and whether they reflect the diversity of the communities we serve.

You only have to answer questions 1-3. The other questions are optional.

The sign-up form will take about one minute to complete.

Want to know how we use your data and keep it safe? Find out here.

Your name (first name and surname)

* required

Maximum 255 characters

0/255

Email address

* required

What would you like to hear about? (Please select all that apply)

* required

Important programme updates

Public event updates and new event announcements

Opportunities to take part in one of our small group conversations (focus groups)

Sign me up for all updates

If you don't have an email address please tell us the best way to contact you in the box below.

Maximum 255 characters

0/255

Do you have any specific needs you would like us to know about to allow you to fully participate in events, in-person and online? Please tell us in the box below.

Have you been to Southport or Ormskirk hospital A&E as a patient or patient carer in the last 10 years (tick all that apply)?

Yes, at Southport Hospital A&E

Yes, at Ormskirk Hospital A&E

No I haven't

Do you work for the NHS?

Yes, I work in a CLINICAL role at Southport or Ormskirk hospital

Yes, I work in a NON-CLINICAL role at Southport or Ormskirk hospital

Yes, I work elsewhere in the NHS

Please tell us which area you live in by putting the first part of your postcode in the box below (for example, ‘PR9’ or ‘WN8’)

Maximum 255 characters

0/255

Are you or have you been an unpaid carer?

Yes

No (go straight to question 27)

What do we mean by unpaid carer?

A carer is defined as anyone who cares, unpaid (or receives a Carer’s Allowance, but is not employed as a care professional), for a friend or family member who due to illness, disability, a mental health condition or an addiction cannot cope without their support.

10.

What is your age?

Under 19

19-30

31-45

46-60

61-75

Over 75

Prefer not to say

11.

What is your sexual orientation?

Heterosexual or straight

Gay man

Gay woman or lesbian

Bisexual

Asexual

Prefer not to say

Other (please specify in the box which will appear)

12.

Do you have a disability, long-term illness or health condition? (Tick all that apply)

Yes, I have a disability

Yes, I have a long-term illness or health condition

No, I don’t

Prefer not to say

13.

What is your biological sex, as recorded at birth?

Female

Male

Prefer not to say

14.

Are you undergoing, have you undergone, or do you propose to undergo any part of a process to reassign your sex?

Yes

Don't know

Prefer not to say

15.

What is your ethnic group? (Please select only one)

Select option

16.

Are you currently pregnant or have you been pregnant in the last year?

Yes

Prefer not to say

Not applicable

17.

What is your religion or belief?

Select option

18.

Have you ever served in the UK Armed Forces (including the reservists or in the part-time service)?

Yes

Prefer not to say

19.

Are you currently ...?

Single

Living with a partner

Married

In a civil partnership

Divorced or civil partnership dissolved

Widowed

Prefer not to say

Thank you for completing this form.

We will keep you up-to-date in the way you have asked us to above.

Please remember to click submit before you go.

Using and protecting your personal data

If you would like to know more about what will happen with your data, click here.