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Telephone: 01942 244 000

Application to become a member of Wrightington, Wigan and Leigh NHS Foundation Trust

Please complete the fields below to submit your application to become a member via our website.

Membership Application Form
Personal Details:
Forename *
Surname *
Date of Birth *
(min. age 16 years)
/ / dd/mm/yyyy
Sex (M/F) *
Address Line 1 * (house number and street)
Address Line 2 *
Address Line 3 *
Post Code *
Daytime Telephone
E-mail

* Denotes required field

Membership (Please tick the box) I confirm I wish to register as a member of the public

 

Ethnic Group (Please select 1 box only)

White Asian/Asian British
British Indian
European Pakistani
Other Bangladeshi
Chinese
Other
Black/Black British British Mixed Race
Caribbean Caribbean/White
African African/White
Other Asian/White
Other

By submitting this form you are declaring that you are eligible to become a member of Wrightington, Wigan and Leigh NHS Foundation Trust and meet the legal minimum requirement.  Members must be at least 16 years of age.

Data Protection Note:
This data will only be used to contact you about NHS Trusts or other health issues and will be stored and processed in accordance with the Data Protection Act.

For Public Members:
The register of Public Members is open for inspection by any member of the public. If you do not consent for your details to be inspected, please tick the box .



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Alternatively, you can:

PDF Document Download a copy of our Membership Application form

Complete the application by hand and send it in using the FREEPOST address on the form. You can also fax the form to us on 01942 822158.

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