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Name: Address: Telephone number: E-mail address: Date of Birth: Your Favourite music: When would be best able to help?   Evenings NO YES Daytimes NO YES Weekends NO YES Any NO YES How would you like to help us?   Ward Visiting NO YES Fundraising NO YES General Admin NO YES Technical NO YES Web-Forum Moderating NO YES Broadcasting / Presenting NO YES Type of programme? How did you hear about us? Word of Mouth At an event Newspaper I know a member of HRE Volunteer agency Patient Hospital visit Work at hospital Other   Personal Referee Name Address Telephone Number Employer Referee Name Address Telephone Number Thank you for completing this form. Please ensure ALL fields have been completed.

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