Family membership form

If you are a parent of a child with hemiplegia complete and submit the Family Membership form. 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 & parent details

We have included detailed questions on this form so that we can understand how we can best help our members and to use anonymously in statistics when we apply for funding. 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:

If 'other' please specify:

Mother's name:

Mother's occupation:

Father's name:

Father's occupation:

PLEASE ENROL ME AS A MEMBER OF HEMIHELP

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.

Declaration: *

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.

Family membership form

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