Membership application form

Title

First name*

Surname*

Address line 1*

Address line 2

Town*

Region

Postcode

Country

Telephone

Email Address*

Gender

Date of birth

Do you consider yourself to have a disability?

If yes please let us know the nature of your disability so that we can try to meet your needs.

What is your ethnicity?

Are there any topics you would like you see at our Public Events?

I am 16 years of age or older*

I am a resident in England or Wales*

I do not work for Medway NHS Foundation Trust*

If you do not wish to be listed on the public register of members tick here:

Declaration