PETITION IN SUPPORT OF CITY HOSPITAL.











Name


Home Address


Contact Number


Email Address


Signature



I AM / AM NOT employed by Sandwell and West Birmingham NHS Trust (Delete as appropriate)



If you are employed by the Trust which Department do you work in?


I wish to be enrolled as a member of The City Hospital Supporters Group. YES /NO (Delete as necessary)



Membership subscription: Medical Staff £5

Non-medical Staff £1

General Public Free


NO PERSONAL DETAILS ON THIS FORM WILL BE SHARED WITH THE TRUST.



PLEASE PUT THIS FORM IN AN ENVELOPE ADDRESSED TO:


CITY HOSPITAL SUPPORTERS GROUP

POSTGRADUATE CENTRE

CITY HOSPITAL

DUDLEY ROAD

BIRMINGHAM B18 7QH