Application to become a Member
By clicking on the "Send" button at the end of the page, this form will be sent to the Gloucestershire Hospitals NHS Foundation Trust. Alternatively please click here for a printable version of the form.
I would like to become a Member of Gloucestershire Hospitals NHS Foundation Trust: Yes
Title Mr Mrs Miss Ms Dr Other
First Name*
Surname*
Full Address *
(Could members of staff please provide an internal work address and not a home address)
Postcode*
Email
Gender* Male Female
Age Group * 16-34 35-49 50-64 65+

Optional Section (by completing this section you help us to make sure our membership represents our community in Gloucestershire)
Ethnic Origin

Gloucestershire Hospitals NHS Foundation Trust Staff only

Please indicate which staff group you belong to. You may also join as a Staff Member if you have worked in a Trust hospital for at least 12 months but are employed by a contractor.

Medical/Dental Nursing/Midwifery Allied Health Professionals/Scientific/Technical Professions Other Non Clinical

Please indicate if you are happy for your work contact details to be passed to your staff Governor: Yes No

* Required fields  
The above information will be retained by the Trust and will only be used in connection with NHS Foundation Trust Status. Names of Members will be included on a public register. No other personal details will be released to a third party without your written authority. The information will be stored and processed in accordance with the Data Protection Act 1998.