All Useful Phone Numbers and Best Times to Telephone

Application form for patient/public membership ofSheffield Motor Neurone Disorders Research Advisory Group (SMND RAG)

When filling this in, please refer to the information in the document entitled ‘Person Specification for SMND RAG’. If you don’t have a copy, please contact Annette Taylor on the details below to obtain one.

Your Name

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Your Address

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All useful phone numbers and best times to telephone

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You must be over 18 years old to apply. Are you over 18?YES  NO

Your Signature

...... Date......

References: Please supply details of {at least one} person we can contact to give a reference:

Their name, title, how you know them, their address, email (if any), telephone:

......

PLEASE USE THIS SPACE TO PROVIDE A BRIEF OVERVIEW OF PERSONAL DETAILS OF RELEVANCE, EDUCATIONAL QUALIFICATIONS AND RELEVANT LIFE EXPERIENCE, EITHER OUTSIDE OF WORK IN LIFE GENERALLY, OR IN WORK.

For example, what knowledge or experience related to MND or neurodegenerative diseaseshave you had? What links have you had, if any, to medical charities?

Why are you interested in being a patient/public member of this group?What contribution do you think you could maketo this Group?

Have you served on a committee before? What were your roles?

The Group role will involve reading and commenting on potentially complex documents. Can you give an example of when you have done that in the past, or willingness to undertake this?

What time commitment do you envisage being able to offer? (Note that the core role only involves four meetings a year, but there may be additional opportunities for involvement in a virtual capacity.)

Do you have any knowledge of emails and computer skills?

Any relevant health considerations such as around venues, transport, personal assistance, need for documents in accessible forms? Are you able to travel to meetings in Sheffield?

{Applicants may also wish to attach a CV or similar, if wished, but this is DEFINITELY NOT ESSENTIAL. If you don’t have one, it makes no difference.}

Please return you application to:

Annette Taylor

SITraN (Sheffield Institute for Translation Neuroscience)

Room B12

385a Glossop Road

Sheffield

S10 2HQ

Tel:0114 222 2289

Thank you

You can email an application instead, or The email should be sent from your own email address, as you won’t be able to sign it.