NHS Foundation Trust membership form
If you are interested in becoming a Foundation Trust member, please fill in the details below and return
it to us.
Title:
Dr
Father
Miss
Mr
Mrs
Ms
Professor
Reverend
Other
First name:
*
Surname:
*
Address:
Postcode:
Borough:
-
Barnet
Camden
City of London
City of Westminster
Enfield
Hackney
Haringey
Islington
Other
Email:
*
Date of birth:
(dd/mm/yyyy)
Telephone:
Have you been a patient at the whittington hospital in the last five years?
Yes
No
If yes, which type of membership would you like
Patient
Public
Please indicate your age group
-
14-16
17-21
22-64
65-80
80+
Please indicate your gender
Male
Female
Please indicate your ethnic group
-
White
White other
Mixed
Asian or Asian british
Black or Black british
Chinese
Other
Do you have a disability?
Yes
No
As a member, how would you like to be kept informed about trust news? (You may tick more than one)
newsletter
email
meetings
Would you be interested in ever running for election to our members' council?
Yes
No
Would you like a list of current elected governors?
Yes
No
Any information you give will be used in accordance with the Data Protection Act 1998.