Become a Foundation Trust member

We need your views and experiences to develop and deliver the very best local Services, to make decisions quickly, invest our money wisely and put the local community first.

Please be aware that any emails you send to the University Hospital of North Staffordshire, and those which we may send to you, are not guaranteed to be secure as email messages may be intercepted.If you prefer to telephone the Foundation Trust department, please call on 01782 555482.

Title:*

Surname:*

First Name(s):*

Address line 1:*

Address line 2:

Town:*

County:*

Postcode:*

Home phone number:*

Moble phone number:

Email:*

Gender:*

Male
Female

Ethnic Group:*

Date of Birth (DD/MM/YYYY):*

Have you been a patient in the last 2 years:*

Yes
No

Are you the carer of a patient:*

Yes
No

I want to become a Foundation Trust member:*

I want to become a Foundation Trust Governor:

* required

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