Membership

Family membership form

If there is someone with hemiplegia in your family, then join HemiHelp. You will not only receive our regular newsletters and other benefits, but you will be part of a growing organisation that is dedicated to helping you.

Do you have hemiplegia yourself? Fill in our Adult membership form.

Correspondence to be sent to:

Title:

First name: *

Surname: *

Address: *

Postcode: *

Tel:

Mobile:

Email address:

Receiving emails:

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

Child's details

We have included detailed questions on this form so that we can understand how we can best help our members, and for use anonymously in statistics when we apply for funding. But please remember that you do not have to answer any questions you don't feel comfortable with.

Child's first name:

Child's last name:

Date of birth

Is your child male or female?:

Male

Female

Main language:

Ethnic origin:

Mother's name:

Mother's occupation:

Father's name:

Father's occupation:

You and HemiHelp

If other, please give details:

If you heard about HemiHelp through a professional at a Hospital / Surgery / Child Development Unit - which one was it?:

Would you like us to send you more information about: :

Local Groups

Pen Pal scheme (for children over 5 years)

PLEASE ENROL ME AS A MEMBER OF HEMIHELP

Membership donation: *

I will pay online by credit or debit card

I will pay by post

I will contact the office about the membership donation

Please tell us how you will pay your membership donation.

Declaration: *

By becoming a member of HemiHelp I understand and accept that this CONFIDENTIAL information will be held on a computer 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 prior written consent.

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