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 agree to accept the Society's liabilities up to a limit of £1 (the Society is a Registered Company limited by guarantee).
  I would like to receive the Society newsletter by email instead of by post. 

Your details will not be passed on to any third parties.

Signed

Date

OFFICE USE ONLY              Rec Date                                                Mem No                                              Pm'nt: Cash/Chq