Public Involvement Group Membership Application
The BRC Public Involvement Groups have been formed to give members of the public and researchers the opportunity to work on developing research that is relevant, appropriate and needed.

Complete the information requested in this application form to apply. The demographic information requested is for equality and diversity monitoring purposes and is anonymised when used to provide data about the membership of the Panel.
It is important in helping us on our journey to equity for all in health research.

The personal information provided will be processed by University Hospitals Birmingham NHS Foundation Trust (UHB) for the purposes of creating and updating your membership details and providing you with information on the various projects we are asked to be involved in.  Please see UHB’s full privacy notice for further details about how the Trust will process your personal information (https://www.uhb.nhs.uk/privacy-notice).

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Email *
Title *
First Name *
Last Name *
Please select your year of birth   *
Do you consider yourself to be a disabled person? *
How would you describe your national identity? (select all the apply) *
Required
If you selected 'Other', please specify here
What is your ethnic group? Choose one option that best describes your ethnic group or background. *
If you selected 'any other ethnic group', please specify here
What is your religion? *
Required
If you selected 'any other religion', please specify here

What is your sex? A question about gender identity will follow

 *

Which of the following best describes your gender?

 *
If you selected 'Prefer to self describe', please specify here
What is the highest level of education qualification you have been awarded? (Please note, no qualification is necessary to be involved with us) *
Your address including postcode *
Home Telephone
Mobile Number
How did you learn about getting involved with the BRC? *
How would you like us to contact you? (select all that apply) *
Required
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