Please read our Guide to KPIN Membership before completing this form.
Please note this form is intended for patients/carers only. If you are a professional, please use the professional membership form.
* indicates a compulsory field
2. Email *
Please tick here to confirm that we can contact you by email: * You can unsubscribe at any time by emailing info@KPIN.org.uk
Any data you enter below will only be used to provide you with appropriate information resources and opportunities, as detailed in our Guide to KPIN Membership
3. Gender *
Please selectFemaleMaleNon-binaryPrefer not to say
4. Date of birth (YYYY-MM-DD) *
5. Ethnicity *
Please selectBlack / African / Caribbean / Black British•African•Caribbean•Any other Black / African / Caribbean backgroundWhite•English / Welsh / Scottish / Northern Irish / British•Irish•Gypsy or Irish Traveller•Any other White backgroundMixed / Multiple ethnic groups•White and Black Caribbean•White and Black African•White and Asian•Any other Mixed / Multiple ethnic backgroundAsian / Asian British•Indian•Pakistani•Bangladeshi•Chinese•Any other Asian backgroundOther ethnic group•Arab•Any other ethnic group
7. Social media usage (Select all that apply)
FacebookWhatsAPPInstagramTwitterDon’t currently use social media
8. I am a ... *
9. Kidney patient experience * (Select all that apply)
Not yet on treatmentAdvanced kidney diseaseUnit haemodialysisHome haemodialysisPeritoneal dialysisTransplantAs a carerOther (please describe)
10. My experience includes: * (Select all that apply)
Informal patient/carer representative in hospital (e.g. advocate/peer supporter)Patient or carer representative in Kidney Patient AssociationPatient or carer representative with a national charityPatient or carer representative on local renal unit or hospital committeePatient or carer representative in local, national kidney project, programme or committeePatient or carer representative in policy committee (such as NICE guidelines group)NoneOther (please describe)
11. Location *
Please selectNorthern IrelandScotlandNorth EastNorth WestYorkshire & HumberEast MidlandsWest MidlandsWalesAngliaLondonSouth WestSouth East
12. Main kidney unit *
Please selectAberdeen Royal InfirmaryAirdrie - Monklands HospitalAntrim Area HospitalAyrshire & Arran: University Hospital CrosshouseBangor - Gwynedd HospitalBasildonBelfast City HospitalBelfast- Ulster HospitalBirkenhead - Arrowe Park HospitalBirmingham HeartlandsBirmingham Queen Elizabeth HospitalBradfordBrighton - Sussex Kidney UnitBristol SouthmeadCambridge - Addenbrooke's HospitalCanterburyCardiff - University Hospital of WalesCarlisle - Cumberland InfirmaryChelmsford - Broomfield HospitalColchester Dialysis UnitCoventry - Walsgrave HospitalDerry/Londonderry - Altnagelvin HospitalDoncasterDorchesterDudley - Russells Hall HospitalDundee - NinewellsEdinburgh Royal InfirmaryExeter Kidney Unit - Royal Devon & Exeter HospitalGlan Clwyd HospitalGlasgow - YorkhillGlasgow Renal and Transplant UnitGloucesterHullInverclydeInverness - Raigmore HospitalIpswich Renal UnitKirkcaldyLeeds - St James's University HospitalLeicester General HospitalLichfield Victoria HospitalLiverpool - Aintree University Hospitals NHS Foundation TrustLiverpool - Royal Liverpool University HospitalLondon - Barts and The London HospitalLondon - Guy's HospitalLondon - King's College HospitalLondon - Hammersmith HospitalLondon - Royal Free HospitalLondon - St George's HospitalLondon - St Mary's HospitalLondon - West London Renal and Transplant CentreManchester Royal InfirmaryMiddlesbrough - The James Cook University HospitalMountainhall Treatment CentreNewcastle - The Newcastle upon Tyne Hospitals NHS Foundation TrustNewry - Daisy Hill HospitalNorwichNottingham Renal and Transplant UnitOmagh - Tyrone County HospitalOxford Kidney Unit and Oxford Transplant CentrePlymouth - Plymouth Dialysis UnitPortsmouth - Queen Alexandra HospitalPreston - Royal Preston HospitalReading - Royal Berkshire HospitalSalford Royal NHS Foundation TrustSheffieldSouthend HospitalSt Helier's South West Thames Renal & Transplantation UnitStevenageStoke - University Hospital of North StaffordshireSunderland Royal HospitalSwansea, Morriston HospitalThe Shrewsbury and Telford Hospitals NHS TrustTruro - Royal Cornwall HospitalUniversity Hospital of Derby and Burton NHS Foundation TrustWolverhamptonWrexhamYork
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13. I would like to receive information on: * (Select all that apply. You can contact us to change this at any time)
KPIN training/eventsJoining a committee/local kidney patient associationPeer supportProduct design feedbackQuality improvementResearch projectsService delivery/policy reviewVolunteering for a renal unitOther (please describe)
14. Would you like to receive the monthly KPIN newsletter? *
15. Security check question: What does the 'K' in KPIN stand for?
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