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  Membership Form
  Fields marked with * are compulsory
  Please tick here if do not want your name to be made available to the public in any register of members.

To become a member you must be 16 years old or over.
* Title:
* First Name:
* Surname:
* Address Line 1:
* Address Line 2:
* City/Town:
* County:
* Postcode:
  Home Telephone:
  Work Telephone:
  Mobile Telephone:
* Email:
* Preferred contact method:
  Ensuring Representative Membership
  We are keen to ensure membership represents the full diversity of the local community.
  Are you:
  Age Group:
  Date of birth:
  Do you have a disability?
  To which ethnic group would you say you belong?
   
  About you and your interests
  How involved would you like to be?
  I would like to be involved in service consultations and questionnaires
  I would like to be invited to attend special events and meetings
  I would like to receive a Members Newsletter twice a year
  I would prefer to recieve the newsletter by email
  I am interested in becoming a governer and would like to know more
   
  I am particularly interested in:
  Outpatients
  Services for Older People
  Children's Services
  Cancer Services
  Heart and Chest
  Infection Control
  Diabetes
  Other (please specify)
 
We will acknowledge receipt as soon as possible. Your household will receive a newsletter in April and October and any events will be publicised in the local media and on the Trust’s website.
 
Your membership details will be stored in accordance with the Data Protection Act.
 
The data will be used only to contact you about the Trust or other health issues.
 
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© 2013 James Paget University Hospitals NHS Foundation Trust
Lowestoft Road, Gorleston, Great Yarmouth, Norfolk, NR31 6LA
Tel: 01493 452452