Membership application form

How would you prefer to be contacted? *

We want to make sure our members come from all parts of society so please tell us your gender and date of birth.

Do you consider yourself to have a disability?
What is your ethnicity?
What are your particular areas of interest? (Please circle as many as you wish)

* Mandatory fields

Your details will be held on a database and will be used by the NHS to provide you with information about the work of the Trust and to administer elections to the Council of Governors. The information will remain confidential and will be held and managed in accordance with the Data Protection Act (1998).