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Membership form

Membership application form

ALL SECTIONS OF THIS APPLICATION MUST BE COMPLETED

Your details

Title:Mr/Mrs/Ms/Other

First Name

Surname

Address

Postcode (Please Include)

Telephone

Would you be willing to receive communications from us by e-mail?

Yes

Do you have a specific area of interest in healthcare? Please tell us what it is.

We are required to publish a Register of Members. If you DO NOT want you name to appear on our register please click this box:

Please tell us if you'd like to be actively involved in helping us by:

Receiving regular news from the Trust

Standing for election to the Board of Governors

Volunteering, or otherwise assisting with patient services

Attending meetings

About you...

We want to involve the WHOLE community - this information will help us to do this.
Please tick where applicable.

Gender

male female

Date of birth (format=dd/mm/yyyy)

Do you have any special needs or disabilities? Yes No

If yes, please feel free to state the nature of your disability to help us meet your needs.

The trust is committed to achieving a policy of equal opportunities. Please help us achieve our aim by completing the following question.

Ethnicity

White

British

Irish

Other White

Black or Black British

Black Caribbean

Black African

Other Black

Asian or Asian British

Indian

Pakistani

Bangladeshi

Other Asian

Chinese

Mixed

White & Black Caribbean

White & Black African

White & Asian

Other Mixes

Other Ethnic Group

How did you find out about our Foundation Trust Application?

Member of Staff

Name

Local newspaper / radio

Name

Other (please state)

Your details will be held on a database so that we can provide you with further information as a member of the George Eliot Hospital NHS Foundation Trust. The information you provide will remain confidential and will be managed in accordance with the data protection act (1998).