Professional Membership Form

Please complete the form to become a Professional Member of HemiHelp.

About you

Title:

First name: *

Last name: *

Job title:

Contact details

Correspondence address

Address for correspondence: *

Postcode: *

Telephone:

Fax:

Mobile number:

Email address:

Using email:

Please tick this box if you do not wish us to send you HemiHelp updates and events news by email.

Work address (if different)

Work address:

Work postcode:

Work telephone:

Work mobile:

Work fax:

Work email address:

You and HemiHelp

Where did you hear about HemiHelp?:

What percentage (approx) of your work involves people with hemiplegia?:

How many people with hemiplegia or families would you refer to HemiHelp each year?:

0-5

6-10

11+

Declaration

Please enrol me as a Professional Member of HemiHelp: *

By becoming a professional 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.

Professional Membership Form

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