Application form

We welcome your application to become a member of Dartford and Gravesham NHS Trust.

By supporting your local hospital and services in this way you can play a real and important part in the future development of your healthcare service. Membership is free.

In compliance with current UK Data Protection legislation, any information you provide here will be kept secure, treated confidentially and used only for the purpose of establishing and developing our Trust's status.

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Govenors/Members Application Form

Please complete this form if you wish to become a member

Title

First Name »

Surname »

Address »

Postcode »

Tel Home: (no spaces)

Tel Mobile: (no spaces)

We would like to contact as many members as possible by email, as this is the most cost-effective and eco-friendly method of communication. So please provide your email address.

Email »

About you - we would like to recruit a membership as diverse as possible in relation to age, gender and ethnicity. Please therefore tell us something about yourself.

Date of Birth

Ethnicity

As a member, you will receive a regular newsletter informing you about the hospital and our plans. If that's all you want as a member, that's fine.

However, if you would like to be more involved with the hospital, please indicate how you would like to be involved by ticking one of the options below (you can change your mind about how much you would like to be involved whenever you like).

Tick applicable

Attending the Trust's Annual General Meeting / Attending talks/presentations about the hospital and its services?
Advising hospital on its services/future plan / Attending community meetings in Dartford, Gravesham and surrounding areas / Becoming a future member of the Council of Governors / Helping to recruit new members / Participating in committees and groups?

Are you interested in volunteering at the hospital?

Are you interested in fundraising?

Are you registered disabled?

I apply to be a member of Dartford and Gravesham NHS Trust and be bound by the rules of the organisation. I give consent to the processing of my information »

Agree

Thank you for taking the time ot complete this form, please click on the submit button below.

Enter the characters as they appear. »

The integration between Dartford and Gravesham NHS Trust and Medway NHS Foundation Trust is currently paused. If the integration does take place please note that all Trust Members of Dartford and Gravesham NHS Trust will automatically be transferred to the integrated organisation, unless such Members tell us otherwise. If you do not wish to become a Member of the integrated Foundation Trust, email kevin.rowan@dvh.nhs.uk.

Dartford and Gravesham NHS Trust provides its service to you, subject to the following terms and conditions for use, which may be updated by the Trust from time to time without notice to you. By using this site you agree to the terms and conditions. Any information submitted through forms on this website are transferred to us by e-mail, will be dealt with by us in accordance with data protection legislation. E-mails are not encrypted (secure) before being sent to us and, as the Internet is not always totally secure, users are sending the information at their own risk.