Membership Application Form

Anyone who is over 14 years old and is a resident of England and Wales can become a member. If you would like to become a member, simpy fill out and submit this application form.

If you would like more information about becoming a member, please contact the Trust
Secretary at TrustSecretary@tavi-port.nhs.uk or 020 8938 2493.

We require the below information in order to register you as a member.

Title: *

First Name: *

Surname: *

Address: *

Postcode: *

Phone:

E-Mail:

We want to be as environmentally friendly as possible and reduce the amount of paper we used by communicating with members via e-mail. If you have an e-mail address, please let us know.

Ethnicity

White:

Black:

Asian or Asian British:

Mixed:

Other ethnic group:

We want to know as much as possible about our members so that we can make sure
our services are relevant to you, which is why we ask for certain personal information.
We also want to know whether you have any special access requirements, to make
sure that we can accommodate all of your needs. This information is kept confidential.

Date of Birth: *

Gender:

Do you have any special access requirements?

Disability:

We would like to know what aspects of our work you are interested in, so that we can keep you informed about the things you want to know about.

We will store this information and will use it to inform you of news, information or events that may be of interest to you.

Please select as many as you like by using the Ctrl key on your keyboard.

Your Interests:

Your Declaration: *

I apply to be a member of the NHS Foundation Trust and be bound by its
Constitution. By clicking on Submit I give my consent to the processing of my information.

Membership Application Form

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Membership Application Form