Join us

1. Type of interest:

Are you be interested in becoming a (select one or both):

Member

Governor - before selecting this option, please read the information for governors (including the Nolan Committee: seven principles of public life).

NB If you apply to be a member of the NHS Foundation Trust you will be bound by its rules, which are subject to legislation and the agreement of a written constitution. A draft of the constitution is available on request.

Please type in your full name and today's date to confirm your interest:

2. Your title:

Miss Ms Mrs Mr Dr

Other:

3. Your first name(s) (REQUIRED):

4. Your surname (REQUIRED):

5. Your address (not including postcode) (REQUIRED):

6. Your postcode (REQUIRED):

(This also helps us to see if we are reaching people

in all the electoral wards in our membership area)

7. Your e-mail address(es) (Optional, but helpful):

8. Telephone numbers (Optional, but helpful):

Home:

Work:

Mobile:

Happy to receive text messages to mobile phone?
Yes   No

9. Are you applying to be a Patient member or Public member?

If you live within the membership area and have also been a patient or carer, you will need to choose which constituency (group) you wish to belong to: 'patient' or 'public'. Eligible staff should not use this form - you will be contacted at work.

Patient member: for patients or carers who are receiving, or have received, services from Addenbrooke's;

Public member: member of the public who lives in our membership area.

10. ACT (optional)

Please tick this box if you consent to your information being passed to Addenbrooke's Charitable Trust - a separate organisation to Cambridge University Hospitals NHS Foundation Trust - so that they can keep you informed of their activities.

11. Information that helps us see if we have reached a wide representation of our users and staff (optional):

a. Your gender:

Female Male

b. Your age:

* NB you must be aged at least 16 years to become a member or governor

c. Your date of birth:

d. Your ethnic group: