Member type	Public
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Capt Col Major Commodore Cllr Master Mayor Imam Lord
First name *
Last name *
Date of birth *	DD MM YYYY
Gender	Not Stated Male Female
	Please enter your postcode and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
To help reduce waste, NHS costs and support the environment, our preferred method of contacting you is by email. If you are happy to be contacted by email, please provide your email address below
Email
Please describe your ethnic origin:	Not stated White Black or Black British Asian or Asian British Mixed Other Ethnic Groups

How would you like to be involved?	Become a governor Sign up new members Fundraise for our Trust charity Trust research Other (please specify)
How did you hear about the membership?	Tick here to tell us

Member type
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Please describe your ethnic origin:
How would you like to be involved?
How did you hear about the membership?

*  I would like to become a member of Black Country Healthcare NHS Foundation Trust and at the point of us coming together with Dudley and Walsall Mental Health Partnership NHS Trust, I am happy to be a member of our new merged Trust - Black Country Healthcare NHS Foundation Trust.
We will keep any information we hold about you confidential in accordance with the Data Protection Act 2018 and General Data Protection Regulation (GDPR). For further information, please refer to our membership privacy notice (data controller) and Civica Engagement Solutions privacy notice (database provider)

The data you supply will be used only to contact you about the Trust, membership or other related matters.

Please tick here if you wish to opt out of the Public Register. By law we have to keep basic information about you as a member. This information is held in a register that any member of the public can request to see, however you can opt out of this by ticking the box above. If you wish to opt out at any time after you have signed up as a member, please contact our membership office on 0121 612 8061 or email bcpft.membership@nhs.net.