Membership Form

Welcome to the Trust Portal of Liverpool Heart and Chest Hospital. If you are interested in what we do and how we work you can register below to become a member of this trust. Please complete the following sections to receive regular information about the Trust.

Fields marked with * are mandatory.

Personal Details

Title
First Name*
Surname*
Address*

Town*
County
Postcode*
Date of Birth (to become a member you need to be aged 16 years or older)	[dd-mm-yyyy]
Gender

Ethnic Group

White British	White Irish	White Other
Black African Caribbean	Black Caribbean	Black Other
Asian Bangladeshi	Asian Indian	Asian Pakistani
Asian Other	Chinese	Chinese Other
Mixed White and Black Caribbean	Mixed White and Black African	Mixed White and Asian
Mixed Other	Unknown

Contact Details:

Telephone Number
Mobile Number
Email Address*

Level of Involvement

As a member I would like to:

Only receive information
Receive information, participate in questionnaires, target surveys, focus groups
Receive information, attend meetings and events
Other (Please specify)

Preferred Method of Communcation

Post

How did you hear about the trust's membership

* I apply to be a member of the NHS Foundation Trust and be bound by the rules of the organisation.

Thank you for taking the time to register. In order for the Foundation Trust to comply with statutory obligations, it must, if requested, make public a record of no more than the name and constituency of each of its members, as listed on the membership database e.g. ‘Mr John Smith – Merseyside’. The purpose of this requirement is to legitimise local accountability by allowing members of the public to see the register. No further personal information will be made public.

However, if you do not wish the Trust to make public your name and constituency then please let us know by e mailing membership.office@lhch.nhs.uk or telephoning 0151 600 1639.