JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
VIP List Sign-Up
Thank you for seeking to register your group, organisation, or department with the CHCP to show your support for patient care. In a few quick steps we'll get you on the register!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full name of person submitting to the VIP list
*
Your answer
Name of group or organisation as you wish it to appear on the VIP register
*
Your answer
I represent a....
*
Hospital Department
Social Care Service
Community Care Service
Charity
Support Group
Other:
Where are you located?
*
Your answer
Does your group or organisation have a website or contact number that you are happy to have displayed on the register?
*
Your answer
Please add a short description of your service. (Optional: you may also add why you wanted to join the register.) This may be displayed with your name on the VIP List.
Your answer
Would you like to receive printed copies of the Chronic Health & Care Passport to distribute amongst the patients you represent?
*
Yes
No
Required
If you answered yes, please supply an email address so that we can get in touch if funds permit another batch.
Your answer
If you like the CHCP, would you be willing to write a brief testimonial for our website?
Your answer
Any other comments or questions?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
