Membership Application Form

We're proud of our hospitals but know they can be even better with your help.

We need as many people as possible to take the step of joining us a member of Warrington and Halton Hospitals NHS Foundation Trust - over 6,700 local people from across Warrington, Halton and the surrounding areas have already become members. In return you will receive regular information from us, a free newsletter, invites to events and the chance to participate in surveys and polls. You can also vote and stand as a public governor in future hospital elections. It’s free of charge and only takes a minute to join.

If you would like to become a Member, please complete this form. Please consider if other Members of your family would like to join. You must be at least 12 years old before you apply for Membership.

Fields marked with a red asterisk * are required

Contact Details

Title:
First Name: *
Surname: *
Address: *
Post Code: *
Home Tel:
Mobile Tel:
E-Mail:

How would you prefer to be sent information about the hospitals and membership?
Post E-Mail

Making the Most of your Membership

Knowing how involved you want to be will help us develop the membership and ensure we send you the right amount of information. There are three levels of membership. All levels can vote in elections for hospital Governors and you can change your level of involvement at any time:

Informed Member
You will be kept abreast of new developments and information regarding the hospitals through a quarterly newsletter and invites to Member only events and meetings. You will also be asked to participate in a number of activities such as detailed surveys; focus groups and special interest events.

Active Member
You might also be invited to join hospital groups, help us in service development meetings and increase your knowledge/skill in specific areas of interest.

Are you potentially interested in standing to be a hospital Governor in the Governor elections? Yes No

I would like to volunteer for the Readers Panels

How did you find out about the Membership?

About You

The data you give will help us see if our Membership is representative of our local communities.

Sex: Male Female

Date of Birth (dd-mm-yyyy): - -

What is your ethnic group? Please tick one of these boxes as appropriate.

Declaration

*	I want to be a member of the Warrington and Halton Hospitals NHS Foundation Trust. I am not a Member of Staff. I am happy for you to use this information.

Thank you for taking the time to register. Your details will be held on a confidential database in accordance with the Data Protection Act 1998.
NHS Foundation Trusts are required to publish a publicly available register of members.
If you DO NOT want you name to appear on the public register please tick this box.

White:
British	Irish	Other
Mixed:
White & Black Caribbean	White & Black African	White & Asian	Other
Black:
Caribbean	African	Other
Asian:
Indian	Pakistani	Bangladeshi	Other
Other Ethnic group:
Chinese	Other	I'd Rather Not Say