Please fill in your details below to become a member of Birmingham Community Healthcare NHS Foundation Trust
We want you to join us as a member and help shape our services
We will keep any information we hold about you confidential in accordance with the Data Protection Act 2018. By law we have to keep basic information about you as a member.
Please note that you must be aged at least 16 to become a member. If you are younger than this, but still wish to be involved, please contact us
Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Staff
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Capt
Wing Commander
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Other
Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Note: If you would prefer to be contacted by post, we will need to share your name and address with a third party to enable printing and postage to you.
Preferred method of contact
Email
Post
Telephone
SMS
We have a statutory duty to try to ensure our membership is representative of the community we serve. We would like to know details of your ethnic background, but would point out that it is optional for you to provide this information.
How would you describe your ethnic origin?
Not stated
White - English, Welsh, Scottish, Northern Irish, British
White - Irish
White - Gypsy or Irish Traveller
White - Other
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other Mixed
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other Asian
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other Black
Do not wish to disclose
Other Ethnic Group - Arab
Other Ethnic Group - Any Other Ethnic Group
2. Additional Information
Please let us know of any requirements that would assist us to communicate with you?
Large Print
Audio tapes
Braille
Language
Easy Read Format
Other (please list in ‘Notes’ section)
Do you have a disability?
No
Yes
Please specify
How would you like to be involved with the NHS Foundation Trust at the current time?
Keep in Touch (receive our annual newsletter, invite to annual members meeting & governor election information)
Receive Opportunities about Getting Involved (receive monthly email newsletter & any additional email communications to self-choose the opportunities that interest you, in addition to ‘Keep in Touch’ information)
Consider standing to be elected as a Governor to join our Council of Governors
Do you have any areas of interest in the services we provide?
Adult Services
Children's Services
Rehabilitation Services
Dental Services
Learning Disabilities Services
Other
Volunteering
Our Trust Charity
We value the experiences of our members. Please can you let us know if you are any of the following: (tick as appropriate)
A carer of someone who is a patient
A Patient / Service User
Have worked for Trust
Other
Trust Volunteer
Partner Organisation
How did you hear about becoming a member of the Foundation Trust?
Through membership team
External - Events
Patient mailing
Received by post
Relative/friend receipt of services
Through an employee of the Trust
Website
Other (please state)
Telephone
3. Review
Member type
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
How would you describe your ethnic origin?
Please let us know of any requirements that would assist us to communicate with you?
Preferred method of contact
Do you have a disability?
How would you like to be involved with the NHS Foundation Trust at the current time?
Do you have any areas of interest in the services we provide?
We value the experiences of our members. Please can you let us know if you are any of the following: (tick as appropriate)
How did you hear about becoming a member of the Foundation Trust?
4. Finish
*
I apply to be a member Birmingham Community Healthcare NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.
Find out more and our online form at
http://www.bhamcommunity.nhs.uk/membership
or email
ft@bhamcommunity.nhs.uk
or call 0121 466 7023. Trust’s membership privacy notice at
https://www.bhamcommunity.nhs.uk/about-us/corporate-information/privacy-notices-and-data-protection/membership-privacy-notice/
We will keep any information we hold about you confidential in accordance with the Data Protection Act 2018. By law we have to keep basic information about you as a member. Please click
here
for full details.
Please tick here if you consent to your details being added to the Public Register.