Introduction

This form is to be completed by a new member. You are eligible to become a member in one category only - patient or public.

If you are already a patient or public member, and have re-applied to become a member, we will cross check your details and contact you.

Fields marked with * are mandatory. By completing the voluntary fields about yourself, you will help us measure and build a representative Foundation Trust Membership.

Employees who are on permanent or fixed term contract of at least 12 months and Trust volunteers, automatically become staff members. Other Individuals who are providing services to the Trust, may apply as staff members by emailing the Foundation Trust Membership Office - [email protected].

Member Type. Please select your category from the options listed.

Title

*First name

Middle name

*Last name

Patient members: If you do not wish to submit a home address, please email [email protected] and you will be be added to the database.

Postcode

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Town or City

Postcode

If you do not wish to submit an email address, please email your details to [email protected] and you will be be added to the database.

The trust is committed to saving money on printing, paper and postage and therefore only communicates regularly with members via email.

*Email

Confirm email

Home telephone

Mobile