Membership

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 check the proper checkbox below.

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.

You can either fill form below or print this offline membership form and return it to The Birthmark Support Group, London, WC1N 3XX

Fields marked with * are compulsory

Personal Details

parent of a child with birthmark
adult with birthmark

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:	*
Address:
City:
County:
Post Code:
Phone:

Doctor's Details

Doctor's Name:
Surgery Name (if applicable):
Address:
City:
County:
Post Code:

If your child has been referred to a hospital

Consultant's Name:
Hospital Name (if applicable):
Address:
City:
County:
Post Code:

Comments

Comments:

tell a friend

print this page

dvd
The Birthmark Support Group has produced a DVD to support its aim of raising the awareness of birthmarks

First Name:	*
Last Name:	*
Birthday (DD/MM/YYYY):	*
Type of Birthmark Medical Diagnosis (include any associated problems):	*