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Foundation Trust Application Form

If you are an employee of the Trust you will automatically become a member and so you do not need to complete this form. Our preferred method of contact is by email and you are required to provide an email address when registering online. Please note that you must be 16 years or older to join. Items marked with a red square are mandatory.

Date of birth
/ /  
Gender


I consider myself to have a
Ethnicity: (You do not have to complete this part of the form but it helps us to ensure we represent all sections of the community)
Ethnicity
















Membership type
Please select:



Membership preferences: I am interested in
Certification

Data protection: By submitting this form you are giving consent for the data you have supplied to be stored on a third party database and used only to contact you about the Trust, membership or other related issues in accordance with the Data Protection Act. Full details are available upon request.

Contact Information

Vida Djelic
Foundation Trust Secretary

Chelsea and Westminster Hospital
369 Fulham Road
London
SW10 9NH

T: 020 3315 6716
E: ftsecretary@chelwest.nhs.uk

Hospital Switchboard
T:
020 8746 8000

Membership and Patient Advice
& Liaison Sevice (M-PALS)

T: 020 3315 6727
E: m-pals@chelwest.nhs.uk