Foundation Trust Staff Membership Opt-Out Form

Applicant Information:

Full Name:

Employment Information:

Position:

Base:

ESR No:

Benefits of Membership:

Before you sign and return the form please read the following information regarding the benefits of being a Member of Yorkshire Ambulance Service:

• As a Member you will be able to work with us to represent the views of your local communities and staff groups, and tell us about your needs.
• As a Member you will be better able to influence YAS Trust Board’s decisions and have a say in shaping future quality patient services and support of staff.
• As a Member you will be able to vote to elect a Staff Governor onto the Council of Governors to represent your views, or stand for election to be a Staff Governor yourself.
• As a Member you will receive regular information from the Trust such as the Membership newsletter.

YAS will in no way discriminate against staff who choose not to become members by opting-out.

Opt Out Information:

If you would like to discuss your potential Opt-Out with a member of the Foundation Trust Team then please contact 01924 584567 or This email address is being protected from spambots. You need JavaScript enabled to view it.

Please State Your Reasons for Opting-Out:

I do not feel that the Trust is working in partnership with me or my staff side representatives. As such I wish to opt out of foundation trust membership, if at a later date the Trust shows that it is able to work in partnership I will consider rejoining as a foundation trust member.

This being my decision I do not require further interview or questioning on the matter by management, which I am aware has happened previously to individuals who have opted out.

I would like to Opt-Out of Membership of Yorkshire Ambulance Service NHS Foundation Trust.  I understand that I will not be able to vote in the election of Staff Governors, and I have read the above information regarding the benefits of being a Member.  I also understand that I can choose to opt back into Membership by contacting This email address is being protected from spambots. You need JavaScript enabled to view it. at any time.

Signature:

Date: