Other family membership form

If you have a niece, nephew or grandchild with hemiplegia, then join HemiHelp. You will not only receive our regular magazines and other benefits, but you will be part of a growing organisation that is dedicated to helping you.

Are you the parent of a child with hemiplegia? Fill in our Parent membership form.

Your details

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.

Details of person with hemiplegia

Family member's first name:

Family member's last name:

Date of birth

Male or female:

Male

Female

Main Language:

Ethnic origin:

If 'other' please specify:

Which side is affected by hemiplegia?:

Left

Right

Do you think his/her hemiplegia is:

Mild

Moderate

Severe

Has he or she always had hemiplegia?:

Yes

If no, how did he or she acquire hemiplegia?:

You and HemiHelp

How and where did you hear about HemiHelp?:

Physiotherapist

Paediatrician

Occupational Therapist

Internet search

Hospital

GP surgery

Other

If 'other' please give details:

Would you like to join either of the following HemiHelp services?:

Local Groups

Pen Pal scheme (for children over 5 yrs)

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 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.

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© HemiHelp is registered as Charity No. 1085349. Registered office: 6 Market Road, London. N7 9PW. HemiHelp is a company limited by guarantee and registered in England and Wales (Registered No. 4156922). Information on this site may not be reproduced without prior consent from HemiHelp.

Other family membership form

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