Membership Reply Form

Please use the link below to download the PDF file of the invitation handout for the Membership Application Form:

Membership Invitation (PDF File 192kb)

You can also contact the Foundation Trust Office and request an application form is sent to you through the post if you prefer.

Gwenny Scott
Membership Development Manager
Foundation Trust Office
Birmingham Children's Hospital
Steelhouse Lane
Birmingham
B4 6NH

Tel: 0121 333 8367

We would like to contact as many Members as possible by email, as this is the most efficient method of communication for us. If you are willing to receive information by email please enter your email address in the box below:

Please complete the following sections to register as a Member of Birmingham Children’s NHS Foundation Trust. This data will be used to contact you about the NHS Foundation Trust or other health issues and will be stored in accordance with the Data Protection Act.

Contact details
Surname:
First Name(s):
Title:

Street address:

 

Town:
County:
Postcode:
Date of Birth
Sex Male    Female
Tel Home:
Tel Mobile:
Email:
Please indicate your preferred mode of contact: Post     Email
If you have a disability, do you require any specific arrangements to enable you to attend membership events? Yes     No
If so please give details
Ethnic Group: (please tick as appropriate)
White: British
White: Irish
White: Other
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Other Asian
Black or Black British: Black African
Black or Black British: Black Caribbean
Black or Black British: Other Black
Chinese or other ethnic group: Chinese
Chinese or other ethnic group: Other ethnic group
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: White and Black Caribbean
Your Membership Constituency:
(please tick one box only for the next two sections: you can only belong to one group, either Patients and Carers or Public)
Patients and Carers
I am a carer of a current or previous patient of the hospital
I am/ have been a patient of the hospital living in Birmingham, Sandwell, Solihull, Dudley, Walsall or Wolverhampton
I am/have been a patient of the hospital and live in Staffordshire, Shropshire, Coventry, Warwickshire, Herefordshire or Worcestershire
I am/ have been a patient of the hospital and live outside these areas
Public
I live in Birmingham, Sandwell, Solihull, Dudley, Walsall or Wolverhampton
I live in Staffordshire or Shropshire
I live in Coventry, Warwickshire, Herefordshire or Worcestershire
I apply to become a Member of the NHS Foundation Trust and will be bound by the rules of the organisation.
Please tell us what you are interested in:
Just receiving information
Being regularly consulted about hospital plans and developments
Participating in focus groups or special projects
Standing for election to the Council of Governors
(you must be 16 years or over)
Volunteering for the hospital
Fundraising for the hospital
Your Interests
Accident & Emergency Family Therapy Occupational Therapy
Anaesthesia Finance Department Oncology
Arts Programme Fundraising Department Oncology / Haematology
Audiology Gastroenterology & Nutrition Orthopaedic Surgery
Chaplaincy Group Management Outpatients Department
Child & Family Information Centre Haemoglobinopathy Unit Paediatric Intensive Care Unit
Child Protection Haemophilia Paediatric Surgery and Paediatric Urology
Cleft Lip & Palate Service Healthcare Commissioning Pals/PPIF
Clinical Chemistry Heart Unit / Ward 11 / Ward 12 Personnel
Clinical Governance Unit Heart Valve Bank Pharmacy
Clinical Inherited Metabolic Disorders Histopathology Physiotherapy
Clinical Photography& Design Services Interpreters Plastic & Reconstructive Surgery
Clinical Psychology IT Play Department
Communications Department James Brindley School Private Patients
Continuing Care Team Legal Services Professional Development Team
Craniofacial Surgery Library Research & Development
Dental Specialties Liver Unit ( Hepatology ) / Ward 8 Respiratory Medicine & Cystic Fibrosis
Dermatology Macmillan Nurses for West Midlands Retinoblastoma Service
Diabetes Home Care Medical Day Care Rheumatology
Dietetics Microbiology / Infection Control Social Work Department
Ear, Nose & Throat Neurology Special Feed Unit
Endocrinology Neurophysiology

Speech & Language Therapy
Education Neurosurgery Theatres
Eye Department Nutritional Care Tumour Registry
Facilities Occupational Health    
Your family and friends
If you would like us to send copies of this leaflet for family members or friends, or a membership form
for the children and young people’s club, please let us know.
Adult membership form: Yes  - If Yes, how many copies
Children’s membership form: Yes  - If Yes, how many copies
Thank you for your interest in becoming a Member. We are required to publish a Register of Members.
if you do not want your details to appear on this register please tick this box



Many Thanks for your application
 
 


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Telephone: Tel: 0121 333 9999 Fax: 0121 333 9998

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