Membership application form

Membership Office
Royal Berkshire NHS Foundation Trust
London Road
Reading
RG1 5AN

Download application form here


Title
Name*
Address*
Post code*
Telephone
Email (we will only use your email address to contact you about membership matters). If you do not have an email address, put NA in the box.*
What is your preferred contact method?	Email post either
About You It would be helful if you would complete this section so that we can see if our membership is representative of the people who use our services.
Are you male or female?	Male Female
Date of Birth (dd/mm/yy) Must be aged 16 or over*
Your ethnicity
Do you consider yourself to be disabled?	Yes No
If 'yes' please specify
I would like to (check all that apply):	Receive regular information Attend meetings or events Consider standing for election to the Council of Governors Become a volunteer
What areas are you interested in?	Outpatients Maternity Elderly care Children's services Cancer Emergency Department Diagnostics Breast screening Medical Museum Dementia Men's health Parkinson's Weight loss Pathology
If you're interested in any other areas not listed above, please state
How are you connected to the Trust?	Carer of someone who is a patient Friend/relative of a patient A patient Volunteer Have worked for the Trust Partner Member of the public
How did you hear about becoming a member of the trust?
This information will be stored and used in accordance with the Data Protection Act 1998.
I do not want my name and constituency to be viewed through the public membership register.
	please tick