Introduction

This form is to be completed if you wish to become a new member of the Cambridgeshire and Peterborough NHS Foundation Trust as either a Public member for Cambridgeshire, Peterborough or the Rest of England, or a Patient member (user of any of the Trust's services as either a patient or as a carer of a patient) for Cambridgeshire, Peterborough or the Rest of England.

If you are already a member of the Trust, you are not eligible to join again under another constituency.

Member type

Additional information

Title

First name

Last name

Middle name

Please provide us with your address so that we know which area you are in, to ensure our activities are distributed fairly.

Postcode

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Town or City

Postcode

The Trust is committed to reducing its carbon footprint and future costs by using email communication wherever possible, so to ensure you receive all future member communications, please provide an email address.

Home telephone

Mobile telephone