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Membership form

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

Public membership application

Please confirm that you are over 11*

Date of birth (dd/mm/yyyy)

Gender*

Male
Female
Other gender identity
Prefer not to sa

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:

British
Irish
Other:

Mixed:

White & Asian
White & Black Caribbean
White & Black African
Other Mixed Background:

Asian or British Asian

Bangladeshi
Indian
Pakistani
Other Asian Backgroun

Black or Black British:

African
Caribbean
Other Black background:

Other ethnic group

Chinese
Other:

Please agree to our privacy statement**

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