Your Involvement

Join Us

If you would like to join our Trust, please fill in the form below.

We will use the details you give to provide you with information, to keep you in touch and for election material. If you provide your email address and or your mobile telephone number, we may use these methods to contact you and save postage.

The information you give us will be held in accordance with The Data Protection Act 1998

Please note: All fields marked with an asterisk (*) are mandatory

Disqualifications from membership

A person may not be a member of the Hertfordshire Partnership NHS Foundation Trust:

If, in the opinion of the Board of Governors, there are reasonable grounds to believe that they are likely to act in a way detrimental to the interests of the trust
If they have, within the proceeding two years been dismissed other than by reason of redundancy, from any paid employment in any NHS body
If their name appears on the Sex Offenders Register
If, within the last five years, they have been involved in a serious incident of violence at any of the Trust’s inpatient, outpatient facilities/units or in the community against any of the Trust employees or registered volunteers

* I have read the information above and confirm that none of the disqualifications from membership apply to me * required
Yes
No

Do you work for Hertfordshire Partnership NHS Foundation Trust * required
Yes
No

Title:

First Name: * required

Last Name: * required

House number or name: * required

Street address: * required

Town: * required

County: * required

Postcode: * required

Date of birth:

Home phone:

Mobile:

Work phone:

Email: * required

Do you wish your name to appear on our public register? * required
Yes
No

Involvement and interests * required
Tick one or more
I would like to be involved in surveys, consultations and questionnaires or volunteering opportunities
I would like to attend special events and meetings
I would be interested in standing for election to the Board of Governors
I am a Service User
I am a Carer
I would be interested in joining the Carers Council
I would be interested in joining the Service Users Council
I would like to be contacted about Service User and Carer Involvement

Gender:
Male
Female
Rather not say

Do you consider yourself, or have you ever considered yourself, to be transgendered?
Yes
No

Do you have a disability?
Yes
No
Rather not say

If Yes, do you have a:

Ethnicity

Religion or Beliefs

Sexual Orientation

Please type in the security number shown: * required

Your reference number for this form is: HPFT-C 38671

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