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. Addenbrooke's Charitable Trust (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: