Membership Application Form

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Foundation Trust

Membership Application Form

Please complete this form to register your interest in becoming a member of the Portsmouth Hospitals NHS Trust.

Getting Involved

Which type of member would you like to become?

Patient?

(Someone who has been treated by the Trust in the last 3 years)

Constituency?

(Someone who lives within the Trust's catchment area)

Associate?

(Someone who does not live within the catchment or who has not received treatment but wants to be kept informed about Trust activities)

Your contact details:

Title

First name(s) *

Surname *

Address

Postcode *

Telephone

How would you like to be contacted? (please tick one)

Post E-mail Telephone

About you:

We would like to involve the whole community and this information will help us do so.

Are you?

Male Female

Birth date: (date/month/year)

Do you consider yourself to have a disability?

Yes No

Are you currently an employee of Portsmouth Hospitals Trust?

Yes No

I have been a patient at Portsmouth Hospitals in the past 3 years

Yes No

I have a particular interest in the following services

As a member I would be interested in:

Receiving regular information
Attending meetings or events
Participating in the election of Council members
Standing for election to the members' Council
Becoming a volunteer

What is your ethnic group?

(if other, please state)

Do you wish to be excluded from the public register?

Yes No

In compliance with current UK Data Protection legislation, any information you provide here will be kept secure, treated confidentially and used by the Trust only for the purpose of establishing and developing their Foundation Trust status.