Membership Application Form

Thank you for completing this form to become a member of the Great Western Hospitals NHS Foundation Trust.
Please take a moment to fill in this form, confirm your details and give us information about yourself and what you want from your membership.
This will help us to develop a membership that meets the needs of the local people.
Your details will be held on a database so that we can provide you with further information as a member of the Great Western Hospitals Foundation Trust.
The information that you provide will remain confidential and will be managed in accordance with the Data Protection Act (1998)

1. Please enter your personal information
Other Title
Last Name
First Name (s)
Middle Name (s)
Telephone Number
Mobile Number
Date of Birth
Email Address
Other Ethnicity (please specify if selected above)

2. Please enter your address
Address line 1
Address line 2
Address line 3
Post Code

3. How would you like to receive information in the future

4. Any Special Information requirements
Audio CD
Large Print
Other special requirements (separated by ;)

5. Membership Involvement Information
Would you like:
To receive information / vote in elections ?
To be more involved - receive information / vote in elections / take part in focus groups / attend meetings ?
We run focus groups to improve our services. Are there any services of particular interest to you ?

6. Disability & Special Needs
Do you consider yourself to have a disability or any special needs ?
If yes, please tell us about it ?

7. Governor Questions
Are you interested in becoming a Governor ?