Title: *

First name: *

Last Name: *

Address: *

Postcode: *

Date of Birth (you must be at least 14 years of age to become a member): *

Telephone: *

Mobile:

Your Details
We want to build a membership that is representative of the communities we serve. The following information will help us to know if we have achieved

Email:

Gender:

Male
Female

Ethnicity:

White British
White Irish
White Other
Black Caribbean
Black African
Black - Other
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian – Other
Chinese
Mixed – White and Black Caribbean
Mixed – White and Black African
Mixed – White and Asian
Other Mixed Background
Other Ethnic Group

Do you consider yourself to have a disability:

Yes
No

Getting involved

Which level of membership would you like?

Level 1
Level 2
Level 3

Level 1 - receive information about the Trust, our services and invitations to members’ and Trust events
Level 2 - as per Level 1, plus invitations to participate in surveys and discussion groups about Trust services and future plans
Level 3 - as per Level 2, plus receive information about being a governor and invites to events for potential governors

You can amend this at any time by contacting us.

Your interests

Please indicate which types of services you are interested in:

Child Health Services
Health and Wellbeing Services
Urgent Care Services
Services for people with Long Term Conditions
Offender Health Services
Dental Services
Specialist Services

Membership Confirmation

I would like to become a member of Bridgewater Community Healthcare NHS Trust *

Date: *

This data will be used to contact you about Bridgewater Community Healthcare NHS Trust and will be stored and processed in accordance with the Data Protection Act 1998.

If you have provided an email address or mobile number we may contact you via these methods from time to time.

Public register of members

We are required to keep a public register of our members. This is a list of the public members’ names and constituency which must be made available to anyone who asks to see it.

If you do not wish to be included in the public register please tick this box.