2gether NHS Foundation Trust:

Membership form

Complete the form below and become a member of ²gether NHS Foundation Trust today. Our privacy statement is here.

Please confirm that you are over 11*
Date of birth (dd/mm/yyyy)
Gender*	Male Female
Title
First name*
Family name*
Address*
Postcode*
email*
Telephone
Preferred method of contact (tick all that apply)	post email
Where did you hear about membership	local press local radio website other
If other, please state where

Please answer the following questions which are for equality and diversity monitoring purposes:
Do you consider yourself to have a disability?	Yes No
Ethnic origin (please select one):
White:

Mixed:
Asian or Black Asian:
Black or Black British:

Chinese or other ethnic group:


Please agree to our privacy statement*

Please enter confirmation code in the box