Birthmark Support Group - Membership form

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BIRTHMARK SUPPORT GROUP MEMBERSHIP FORM
Please Note - Membership is currently restricted to UK Residents only. Membership is free and no subscription is charged. However we are a voluntary organisation and are only able to operate with the help of people's kind donations. If you would like to make a donation to the group please see the funding page for details. The membership form was originally designed for parents of children with birthmarks. If you are an Adult with a birthmark you can still use the form. Simply enter your name in the appropriate (male/female) Parent's name box. Leave the Child's name box and your partner's name boxes empty. However do please include your Date of Birth in the Child's Birthday box. This will enable us to identify you as an adult member.
Your details will be stored on a database and kept in accordance with the Data Protection Act 1990. All information supplied will not be shared without your express permission.
Any boxes that are not applicable should be left blank
Personal Details
Child's First Name:
Child's Last Name:
Child's Birthday (DD/MM/YYYY):
Type of Birthmark Medical Diagnosis (include any associated problems):
Female Parent First Name:
Female Parent Last Name:
Male Parent First Name:
Male Parent Last Name:
E-mail Address:
Address1:
Address2:
Address3:
City:		County:
Post Code:		:
Phone:
Doctor's Details
Doctor's Name:
Surgery Name (if applicable): :
Address1:
Address2:
Address3:
City:		County:
Post Code:
If your child has been referred to a hospital
Consultant's Name:
Hospital Name (if applicable):
Address1:
Address2:
Address3:
City:		County:
Post Code:
Comments
Comments:

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BIRTHMARK SUPPORT GROUP MEMBERSHIP FORM