HAEMOCHROMATOSIS
Application for membership
 

This form should be printed out (choose File, Print in your browser menu), completed (in capital letters please) and sent to us with the correct payment.


Full Name:Mr/Mrs/Miss/Ms

  

Address:

 

 

Postcode:
Home Phone: email

Who has Haemochromatosis? Myself / Family Member (specify) / Other (specify)

 
How did you hear about the society?
Would you like to meet other members?                                      Yes / No
May we include your name in our newsletters?                           Yes / No

Membership is £10 per year, concessions £5 [pensioners, unemployed, low income]. Donations are welcomed.
Please make cheques payable to the Haemochromatosis Society.
I enclose membership fee of £ .............

 I am a taxpayer and I would like any subscriptions/donations to be treated as Gift Aid until  further notice.
 I would like to receive the Society newsletter by email instead of by post.

I agree to accept the Society's liabilities up to a limit of £1 (the Society is a Registered Company limited by guarantee).
Signed Date
OFFICE USE ONLY              Rec Date                                                Mem No                                              Pm'nt: Cash/Chq
 
Registered Company Number 2541361                                                                                                                                        Registered Charity Number 1001307


Thank you for completing this application, please post it to:
The Haemochromatosis Society, Hollybush House, Hadley Green Road, Barnet, Herts. EN5 5PR