Consumer / Carer Expression of Interest

Please download the form and send to:
Midland Cancer Network
Private Bag 3200, Hamilton 3240

Or fill out the form below.

Expression of Interest Form

Name
Address
Phone
Email
Ethnicity

The Midland Cancer Network will only use your contact details to contact you regarding possible participation in cancer service improvement activities as a consumer or carer representative.

Have you personally had experience of cancer?  Yes    No

Have you been a carer/close family member of a person who has experienced cancer? Yes   No

Are you involved in a consumer/carer cancer support group? Please provide brief details.

Briefly tell us why you would like to participate in improving cancer services in Midland.

How would you like to contribute?

  As a consumer or carer representative on the Consumer and Carer Reference Group?

  As a consumer or carer involved in a patient focus group that informs the patient mapping programme?

  By attending annual consumer/carer forums?

  I am willing to be approached to provide comment from a consumer or carer perspective on specific documents/strategies.

  I would like to be kept informed about the work of the Midland Cancer Network.