Salisbury NHS Foundation Trust

Membership Application Form

Thank you for completing this form to become a member of the Salisbury NHS Foundation Trust.
Please take a moment to fill in this form, confirm your details and give us extra 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


   
1. Please enter your personal information
Title
Other Title
Surname
First Name (s)
Initials
Telephone Number
Mobile Number
Date of Birth
I am
Email Address
Ethnicity
Other Ethnicity
Staff Group   Click here for more details



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



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



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



5. Membership Questions, would you like:
To attend membership meetings which are of interest to you ?
To receive regular newsletters, or information about the Trust ?
To be contacted about surveys or projects that we would like you to help us with ?



6. Disability & Special Needs
Do you have a sensory or physical disability?
Do you have any special needs ?
Knowing about your disabilities or special needs could help us to communicate and work with you better. If you are happy to share details, please provide the information.



7. Governor Questions
Are you interested in knowing more about the role of governor ?

   
Your details will be held on a database so that we can provide you with further information as a member of the Salisbury NHS Foundation Trust.
The information that you provide will remain confidential and will be managed in accordance with the Data Protection Act (1988)
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