Membership Form

Please fill in this form to apply for membership of the Foundation Trust. Musgrove Park Hospital is committed to equal opportunity. You do not have to answer all the questions, but doing so will help us to ensure that our membership reflects the diversity of our local community (those marked with * is required information).

Your Name

Your Email (if you do not have an Email address, please enter ''''noemail@noemail.co.uk'''')

Title

If ''other'' please state:

Surname

Forename (s)

Address

Postcode

Date of Birth

Home telephone number

Mobile telephone number

If you are a Musgrove Park Hospital employee, please indicate which staff group you belong to

Sex

What is your ethnic group?

What is/was your primary occupation?

Do you have any sensory or physical disability or special needs?

Knowing helps us to communicate better with you. Please indicate if there is anything that we can do to help you in this respect e.g. publications in larger print or in languages other than English

I support plans to replace the 1940s buildings with a new surgical ward block

I would like to receive information on:

No further information required
Being consulted on hospital plans
Participating in focus groups and projects
Standing for election as Governor
Volunteering for the hospital
Fundraising for the hospital
Specific department or area

If "specific department or area" please state

I would also like to become a Foundation Trust member for Somerset Partnership NHS Foundation Trust (Mental Health and Social Care)

How did you hear about becoming a member?

If "other" please state

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