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
Telephone
Date of Birth
Gender* Male Female
Optional Section (by completing this section you help us to make sure our membership represents our community in Gloucestershire)
Ethnic Origin

Level of Involvement - please indicate what you are interested in (you may click more than one)

 Recieving news and information about the hospitals

Being invited to seminars/tours/ meetings and events
Being asked for my views on future plans

Please select which group you belong to:

 

 

    
A Patient
A Member of the Public
A parent / carer

Please tell us how you found out about membership

 

    
Friend/Family
Hospital Staff
Website
Governor
Recruitment Campaign
 
If you were introduced by a Staff Member, please enter their details below:
Name
Department
Contact Number
Email

 

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. The information will be stored and processed in accordance with the data protection act 1008. If you do not with to have your name included on the public register please tick here:

 

* Required fields