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Trust Membership

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*

Address*

Postcode*

Email*

Sex*

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

Tel No.*

Membership

Ethnic Group (Please select just one)

White

Asian/Asian British

Black/Black British

British Mixed Race

Religion

Sexual Orientation

Disability

We would also like to ask some additional questions about you:

Are you a veteran?

This is anyone who has served for at least one day in Her Majesty’s Armed Forces (Regular/Reserve) or Merchant Mariners who have seen duty on legally defined military operations)

Are you a carer?

This is anyone who looks after, or gives help or support to family members, friends, neighbours or others because of either long term physical or mental ill-health/ disability, or problems related to old age)

Service user information

Do you suffer with or have you ever suffered with any of the following health issues?

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