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. 
Member type
Title
First name *
Last name *
Middle name
Date of birth *
Gender
  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 




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?