Poole Hospital NHS Foundation Trust

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Register of Interest and Member Registration Form

In compliance with current UK Data Protection legislation, any information you provide will be kept secure, treated confidentially and used only in connection with membership and public involvement.

Your information

Title:
First name:
Last name:
Address
House number or name:
Street:
Town:
County:
Postcode:
Telephone number:
Email address:
Date of birth (dd/mm/yy):

Would you prefer to receive information by:
Letter Email
Please say which local authority area you belong to:

Getting Involved

I would like to become a member of Poole Hospital NHS Foundation Trust. When I become a member I would like to:
Receive regular information
Attend meetings or events
Participate in the election of the Council of Member Representatives
Condider standing for election to the Council of Member Representatives

Ensuring equal access for all We want to involve the whole community - this will help us to do so.

Are you:
Male Female

What is your ethnic group?:

Do you consider you have a disability?:
Yes No
Are you employed by Poole Hospital?:
Yes No
Have you been a patient in the last three years?:
Yes No

I have a particular interest in the following services: