Online Membership Form

Title*
First Name*
Surname*
Home address*
Postcode*
Home Phone number
Mobile phone number
Email
Gender*
Your date of birth*
We will contact you by email, if you prefer to be contacted by post please indicate below.
- Post
Please tick here if you do NOT wish your name to be included on the public register.
Disability
- I consider myself to have a disability
- I do not consider myself to have a disability
Meetings/Events
Standing a Governor
Volunteering
White
Mixed
Asian or Asian British
Black or Black British
Other ethnic group
Data Protection
The information on this form will be kept by Cornwall Partnership NHS Foundation Trust and only used in connection with membership and public involvement. Except where you agree that your name may appear on the public register, the information will not be released without your written authority. This is in accordance with the General Data Protection Regulations (GDPR) and Data Protection Act 2018.
Email
This field is for validation purposes and should be left unchanged.

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