Join Embrace and work with us Home > Tell us what you think > Embrace – real people, real opinions > Join Embrace and work with us Please fill out the form below to join Embrace. If you have any problems filling out or submitting the form, please see this page for information on other ways to register. Step 1 of 5 20% TitleMrMrsMsMissDrOther (please specify)If other, please specifyFirst name(s)*Surname*Address*Postcode*Home telephone numberMobile telephone numberEmail addressWe would like to contact as many Embrace members as possible by email, as this is the most cost-effective method of communication.Are you registered with a GP practice in the North Lincolnshire area?YesNoWhich practice? Your interestsPlease select your interests: Care of older people Dementia services Dermatology services Discharge from hospital End of life care GP referrals Carers and care services Long term conditions (e.g. diabetes, asthma, arthritis, Parkinson’s etc.) Managing your own condition (self–help or self–care, expect patients etc.) Women and childrens’ services Mental health services for adults Mental health services for children Ophthalmology Orthopaedics (including physiotherapy) Disabilities (e.g. physical, mental, sensory) Patient information (leaflets, DVDs etc.) Prescribing Rehabilitation services Services working together in the community (e.g. closer working between health and social care) Urgent care and Accident and Emergency How I want to be involvedPlease select how you want to be involved: Attend focus groups/workshops on your areas of interest Help make our information easy to understand Take part in surveys Monitoring informationGenderMaleFemaleTransgenderPrefer not to sayDate of birth*Do you consider yourself to have a disability or a long term health condition?YesNoDo you require large print information?YesNoIf you require information in a language other than English, please specify the languagePlease specify any other requirementsDo you consider yourself to be a carer? (eg. caring for someone with a long term health condition, disability, or special need?)YesNoWhat is your ethnic group?White/White BritishAsian/Asian BritishChineseMixed/multiple ethnic groupBlack/African/Caribbean/Black BritishPrefer not to discloseAny other ethnic group (please specify)If other, please specify A bit more about you...We’d like to get an idea about why you are joining Embrace and if you have any other local networks that you’re involved with. Please tick any/all that apply out of the following: I live in the North Lincolnshire area I am a member of my GP practice Patient Participation Group I am a member of Healthwatch I am a volunteer with a voluntary sector organisation (please specify) I am a member of staff in a voluntary sector organisation (please specify) I don’t live in the area but I do access health services in this area I am a Foundation Trust member I am a locally elected representative (e.g. Councillor) I am a member of staff in an NHS organisation, the local authority or other statutory local service I am a member of staff in a care home/residential home/other care setting If you are a volunteer at a voluntary sector organisation, please specify whichIf you are a staff member at a voluntary sector organisation, please specify whichConfidentiality and Data Protection: In accordance with current UK Data Protection legislation, any information you provide on this form will be kept secure, treated confidentially, and only used for the purposes of developing and maintaining our public engagement via the EYPPEN membership. Your personal information will not be shared with any other agencies. If at any time you wish to leave the database please contact us.CommentsThis field is for validation purposes and should be left unchanged.