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I want to become a member

28 September, 2012

To become a member, you can fill in the application form below, or contact the membership office here for a hard copy application form

* Indicates required answers

 Registration Form 
Contact Details
We would like to contact as many Members as possible by email, as this is the most cost-effective method of communication.
Membership is not limited, we would like to encourage others in your household to become Members. Add their details as follows:
Sharing information 
We want to build a Membership that is representative of the whole community.
Please tick one of the following boxes to describe your ethnic origin *
  • White
    British
    Irish
    Any other White Background
     
    Asian or British Asian
    Indian
    Pakistani
    Bangladeshi
    Any other Asian Background
     
    Black or Black British
    Caribbean
    African
    Any other Black Background
     
    Mixed
    White and Black Caribbean
    White and Black African
    White and Asian
    Any other Mixed Background
     
    Other Ethnic Groups
    Chinese
    Eastern European
    Any other ethnic group
Gender 
Are you a 
Please note that the NHS Foundation Trust is required to publish a publicly available register of Members.
In accordance with both European law and the Data Protection Act 1998, Members have the right to choose if their personal data is disclosed.
Please help us by providing the following information
How did you find out about becoming a member?

Call us on 0191 482 0000

In emergencies dial 999 / Non-emergencies dial 111
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