Foundation Membership

Title
Mr Mrs Miss Dr Sir

First name

Surname

Date of birth (dd/mm/yyyy)

Telephone number

Mobile

Gender
Male
Female

Ethnic origin
White
Black or Black British
Asian or Asian British
Mixed
Chinese or other ethnic group

Have you ever been a patient of the hospital?
No
Yes
If so, when?

How did you hear about membership

Are you a member of any other trust?
No
Yes
If so, please state which trust you are a member of?

Specific areas of interest?
Maternity services (Pregnancy care)
Gynaecology (Disorders and conditions of the female reproductive)
Fetal Medicine (Care for babies inside the womb)
Neonatal Intesive Care (Special care and support for babies)
Genetics (Inherited disorders and conditions)
Other interests

Please tell us what activities you would like to be involved in
I would be interested in becoming a governor in future elections to the trusts council of governors
I would like to attend focus groups and special events
Volunteering
Receiving a quarterly Women's progress magazine