+A+A+A background: Change background to yellow Change background to white
Home > Have your say > Foundation Trust > Apply to be a member online

Apply to be a member online

Staff are automatically opted in as members and therefore do not need to complete this form. For further information on staff membership click here

Please fill in the form below or if you prefer you can print the Membership Application Form (pdf version) – to fill in and post to us.


First Name (required)

Last Name (required)

House Number/house name (required)




Postcode (required)



 male female

Date of Birth (required) (mm/yyyy): /

We would like to contact as many people as possible by email, as this is the most cost effective method of communication. If you are willing to receive information by email, please provide your email address:


Are you currently:
 Someone uses the Services of the Trust? A carer of someone who uses the services of the Trust? A local resident?

Please indicate the Residential Area that you represent:


Please give details if you answered other to any of the above:

Your involvement:

You can be involved as much or as little as you want to, please indicate what you would be interested in:

 Receiving regular newsletters/information Attending meetings or events Being a volunteer in the Trust Being involved in focus groups relating to your area of interest Standing for Election as a Governor (if nominated) Becoming a Non-Executive Director

Do you belong to an organisation or group that may like more information? If so, please indicate the name of the group and any contact details :

I have a particular interest in the following areas (Choose as many as you wish) :

 All of the list Accident and Emergency Appointment letters/Booking Cancers Car parking Care of the Elderly Children’s services Cleanliness Community Hospitals Dental Dietetics Disability/equality District Nursing Ears Nose & Throat Emergency Medicine End of Life care Eyes Food Foot care Hearing problems Heart disease/cardiac services Infection Control Intensive Care services Kidneys Maternity care Minor Injury Units Multiple Sclerosis Neurology Nursing Occupational Therapy Orthopaedics Outpatient services Patient information Physiotherapy

Special Conditions:

 Rehabilitation Respiratory Rheumatology Sexual Health Social Care Speech & Language Therapy Stroke Skin Surgery/Anaesthetics Volunteers Vulnerable adults (protection of) Women’s services Wound care X-Rays, scans & tests

OTHER (not listed)

Where did you hear about our FT membership?
e.g. Media, picked up form in outpatients area, another member, staff member (please let us know their name)

Please tick the box if you wish to opt out of receiving future fundraising news.

 I wish to opt out of receiving future fundraising news

We are obliged to keep the information you submit on a public register. If you do not wish this to be the case, please tick this box.

 Do not store my information

This information will be stored and used in accordance with the Data Protection Act 1998. The information provided will only be used by the Trust for NHS Foundation Trust membership