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Membership Form

I would like to become a member and be able to influence the future of my local hospitals and:

  • receive regular updates on news and developments at my local hospitals
  • attend (optional) annual members’ meetings
  • help decide who sits on the Trust's ‘Council of Governors’ by voting in future governor elections
  • stand for future elections myself to have the chance to sit on the Trust’s ‘Council of Governors ’
  • register my special health interests for use in staff and patient involvement initiatives (eg focus groups)

CHFT - 429 - Membership Form

Eligibility
I am eligible to become a member as I am over 16 years of age and fit into one or more of the following categories (please tick all boxes that are appropriate):*
Personal Details
Gender*
Ethnic Classification
We are committed to ensuring that NHS Foundation Trust Membership is representative of the whole community. We, therefore, welcome applications from persons of any persons aged 16 years or over and of any race, colour, religious belief, ethnic or national origin, sexual orientation, gender, disability or marital status. It would be very helpful if you completed the following categories. THIS INFORMATION WILL BE HELD IN CONFIDENCE AND WILL NOT BE ATTRIBUTED TO ANY INDIVIDUAL.
To which of the following ethnic groups do you belong? Choose ONE section from A to E, then mark the appropriate box to indicate your cultural background:*
Public Register
Data will only be used to contact you about NHS Foundation Trusts or other health issues and will be stored and processed in accordance with the Data Protection Act.
Extra Information
As a member what are your areas of interest? (please indicate with a tick all those you are interested in):
Would you like to be involved in:
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