Adult Membership Form

Please complete and submit the form.

About you

Title:

First name: *

Surname: *

Date of birth

Are you male or female?:

Male

Female

What is your ethnic origin?:

If 'other' please specify:

What is your main language?:

Contact details

Address: *

Postcode: *

Phone number:

Mobile number:

Receiving emails:

Please tick this box if you do NOT wish us to send you HemiHelp's updates and event news by email

Email address:

Additional information

Which side is affected by hemiplegia?:

Left

Right

Do you think your hemiplegia is:

Mild

Moderate

Severe

Do you think you have always had hemiplegia?:

Yes

Unsure

If no, how did you acquire hemiplegia?:

Your age when diagnosed:

Employment

Are you currently:

Employed

Self-employed

Seeking employment

Unemployed

Please tell us about the type of work you do or have done:

If you are seeking employment, what kind of work are you looking for?:

You and HemiHelp

If 'other' please give details:

HemiHelp has a scheme, which can put you in touch with other adults who have hemiplegia, would you like further info?:

Yes

Declaration

Please enrol me as an Adult Member of HemiHelp.: *

By becoming a member of HemiHelp I understand and accept that any information pertaining to me will be held securely on a confidential database under the rules of the Data Protection Act and will be for the exclusive use of HemiHelp, who undertake not to disclose this information to any other organisations without my prior written consent.

Membership subscription: *

I will pay online by credit or debit card

I will pay by post

I will contact the office about my membership subscription

Please tell us how you will pay your membership fee

Adult Membership Form

Search

Stay in touch

Quick links