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.

Personal Details:

* Forename:

* Surname :

* Date of Birth :

* Sex
Male
Female

* 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
Yes

Ethnic Group (Please select 1 box only)
White
British
European
Other

Asian/Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other

Black/Black British
Caribbean
African
Other

British Mixed Race
Caribbean/White
African/White
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 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
No

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