Membership Registration Form

Your details

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 1

Town *

Postcode *

Home Telephone

Mobile Telephone

Date of Birth

Disability

Do you consider yourself to have a disability?

Yes
No
Prefer not to say

If Yes please state

I need the following adjustments

Membership Type

Public
Service User / Carer (in the last three years)

How did you find out about membership?

How did you find out about membership? Local newspaper/radio

From a member of our staff - please tell us their name:

Data Consent

Your information will be held securely and confidentially in accordance with data protection legislation. The Privacy Notice explains how we use members data and your rights under the UK General Data Protection Regulation (UK GDPR). If at any point you no longer wish to be a Member of our Trust please call our Membership Office on telephone number: 01482 389132 or email: hnf-tr.members@nhs.uk

We are required to publish a Register of Members. Please tick below if you consent to your details being added to the Public Register.

I consent to my details being added to the Public Register.

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