Manchester Mental Health and Social Care Trust

Foundation Trust Membership Form

Thank you for your interest in joining our Foundation Trust. Please fill in the form below so we can register you as a member.

Fields marked with an * are required.

Membership Form

Personal Details

Title *

First name *

Surname *

Address *

Postcode *

Telephone

Email Address *

Membership

Where you live will determine which group (constituency) you belong to. Please indicate the public constituency that you are joining *

North Manchester

South Manchester

Greater Manchester

Out of area

Level of Involvement

Are you interested in: Receiving regular information & news of member’s events
Voting in the Governor elections
Becoming a Governor
Attending/helping at events
Volunteering
Other If other, please state

In order to ensure that our membership is representative of the local population, it would help us to collect the following data. The information you give will be protected in accordance with the Data Protection Act 1998. The information will be held on a stand alone database and will never be shared with any outside body or any Trust function other than Foundation Trust matters.

Gender * Male
Female

Date of birth *

Ethnic group

Do you consider yourself to have a disability? Yes
No

How would you like us to contact you? *
E-mail
Post

Please help us by telling us how you found out about the opportunity to become a member Newspaper article
The Trust's website
Friend/relative/colleague
Leaflet about membership
At a public meeting
At a roadshow
Other If other, please state

Ancoats & Clayton, Ardwick, Bradford, Charlestown, Cheetham, City Centre, Crumpsall, Harpurhey, Higher Blackley, Gorton North, Gorton South, Longsight, Miles Platting, Newton Heath, Moston.

Baguley, Brooklands, Burnage, Chorlton, Chorlton Park, Didsbury East, Didsbury West, Fallowfield, Hulme, Levenshulme, Moss Side, Northenden, Old Moat, Rusholme, Sharston, Whalley Range, Withington, Woodhouse Park.

Bolton, Bury, Oldham, Rochdale, Stockport, Tameside, Trafford, Wigan, Salford.

The remainder of England and Wales.