I wish to be registered as a member of Somerset Partnership NHS Foundation Trust. I am aged 12 or over and agree that my name can be placed on the Register of Members, which is a public document.
If you do not want your name to be seen on the Register of Members, please tick the box. .

Please complete all sections of this form and click on the submit button:

Title:  Please select Dr Mr Mrs Ms Miss Professor Rev. Lord Lady

Name:

Address:
 

Postcode: 

Day Time Telephone: 

Email:

Preferred method of contact: Please select Post Telephone Email

About You

We would like to know some information about you. This will help us to make sure that people from all backgrounds are involved with the NHS Foundation Trust and have a say in the way we develop services. This information will remain completely confidential and will be used for monitoring purposes only. Please tick where applicable. 

Gender:  Please select Male Female

Date of Birth (minimum age 12):

What is your ethnic group? Please select White British Irish Any other white background White and black African White and black Caribbean White and Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other black background Chinese Other ethnic group

Are you interested in any particular service of the Partnership Trust?

Membership

What sort of member would you like to be? Please select Public - living in West Somerset Public - living in Sedgemoor Public - living in Mendip Public - living in Taunton Deane Public - living in South Somerset Public - living outside of Somerset Service User Carer Staff

If you are unsure which membership group you are eligible to apply for or wish to receive a membership information pack, please contact Ria Zandvliet on 01278 432073.

How did you hear about our NHS Foundation Trust application?