Young influencers interest form

Full Name *

How would you like us to address you? (optional)

Tell us your names' pronunciation, your pronouns or nickname

We welcome volunteers with a wide range of skills and experiences. We ask these questions because we want to accommodate your unique circumstances in order to do that we must understand them first. It is your choice whether or not to tell us anything *

Mobility impairment (requiring a lift)
Anxiety
Dyslexia
Hearing impairment
Visual impairment
Immunocompromised
Other
None

If there are any arrangements we could make to help you do your role (eg: ground floor position, sign interpreter, buddy etc), please let us know in 'Other'.

Email Address *

Contact Number *

Consent to be added to young influencers whats app group *

Yes
No

Date of Birth *

Name of education provider (if in education) *

Emergency contact *

How did you hear about the programme?

What is your first language? *

Do you speak any other language?

Do any of the following apply to you? (tick all that apply) *

Patient of Gloucestershire Hospitals Foundation Trust
Former patient of Gloucestershire Hospitals Foundation Trust
Sibling of a patient / former patient of Gloucestershire Hospitals Foundation Trust
Know someone who currently works at the hospital
None of the above and would like to learn more about the Trust and influence services out of personal interest
Other

Which of the following areas really spark your interest? *

With which gender do you identify? *

What is your ethnic origin? *

Do you consider yourself to have a disability (as defined in the Disability Discrimination Act) of which you would like to us to be aware? *

Yes
No

If yes, provide details

If there is anything else you would like us to know when considering your application, or if you have had difficulty using the form, please let us know here. *

*

Preparing for your visit with us: Before you arrive, during your stay and how we'll look after you

Find out more about our specialist children's services

Donate to our hospitals charity to support one of our appeals!

Need to cancel or change your appointment? Let us know ASAP.

Young influencers interest form