Apply to become a member of Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

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

 

Forename*

Surname*

Date of birth* Please use dd/mm/yyyy format

Sex*

Address*

Postcode*

Tel No.*

Email*

Membership

Ethnic Group (Please select just one)

White

Asian/Asian British

Black/Black British

British Mixed Race

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 further information on how we use your data please see the Trust's privacy notices available here: Trust Members Privacy notice

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

Royal Albert Edward Infirmary
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Wrightington Hospital
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