Membership

Professional Membership Form

Please fill in this form in order to become a Professional Member of HemiHelp. Find out why you should join!

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 (approximately) of your work involves children with hemiplegia?:

How many children 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 member of HemiHelp I understand and accept that this CONFIDENTIAL information will be held on 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 my prior written consent.

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