Become a Member

Published/updated: 28/01/14 14:31

To become a member of the Trust complete and submit the form below. Details provided are in confidence and will only be used for Trust purposes. Alternatively, you can call the Membership hotline on 0121 424 1218

Membership Application Form

 

 

How involved would you like to be?

Where did you hear about membership?







If you have a particular interest in one or more areas of healthcare, we'd very much like to know. Please tell us here:



















 

Have you ever been a patient in Heartlands, Good Hope, Solihull hospitals or in the Birmingham Chest Clinic?

Do you care for somebody who is a patient in Heartlands, Good Hope, Solihull hospitals or in the Birmingham Chest Clinic?

Please let us know your employment status

If other, please state:

Are you male or female?

What is your ethnic origin?














 

Are you registered disabled?

If you need us to send you information in any of the following formats, please tick the relevant boxes:

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