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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

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

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?

*  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.ukor 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.