Foundation Trust Application

» Membership Form


Membership Form

To register as a member, please complete the following form.

* Remember, if you are a member of staff at West Herts Hospitals NHS Trust, you have automatically been made a member and do not need to complete a membership form.

Fields marked * are mandatory

Contact Details

*
*

Date of birth
* * *

Address
*
*


*



We'd like to email you, but if this isn't possible, please state your preference:

Personal Details

(Please select from the list the ethnic group to which you feel you belong.)

I would like to:

Areas of Interest










Where did you hear about us?

Please enter your comments below

I was recruited by (their name):

Top of page ^^

Why are we asking for this information?

We are the West Hertfordshire Hospitals NHS Trust. We will hold this information for the purpose of Membership recruitment. For further information, please contact Heather Britton, Foundation Trust Membership Manager, at the Foundation Trust Office, or telephone 01923 436281.

Information provided will be dealt with in accordance with the Data Protection Act 1998 and will not be passed on to third parties without your prior consent, unless it is lawful to do so.