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BECOME A MEMBER
LHM Membership Form – Parent of a child with a single ventricle heart
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LHM Membership Form – Parent of a child with a single ventricle heart
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LHM Membership Form – Parent of a child with a single ventricle heart
Your Details
Your Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Your relationship to child
(Required)
Email
(Required)
Phone Number
(Required)
Facebook profile name
Some people use a different name on social media. Providing this will help us speed up your acceptance into our private groups.
Your ethnicity
White
Mixed
Asian or Asian British
Black or Black British
Chinese
Any other ethnic background
Your Partners full name (If no details please put n/a)
(Required)
First
Last
If the address is the same as above please tick box, if different please fill out address information below (if no details available please tick "Same as above" box)
Same as above
Address
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Relationship to child
(Required)
Email (if no seperate email address please repeat earlier email address)
(Required)
Facebook profile name (if no profile name please put none)
(Required)
Some people use a different name on social media. Providing this will help us speed up your acceptance into our private groups.
Their ethnicity
(Required)
White
Mixed
Asian or Asian British
Black or Black British
Chinese
Any other ethnic background
Child's Details
Heart Child's Name
(Required)
First
Last
Child's Date of Birth
(Required)
Day
Month
Year
Child's Gender
(Required)
Male
Female
Child's Diagnosis
(Required)
Please give as much detail as possible here. If you are unsure about the diagnosis, what has your doctor / consultant said about future treatment?
Supporting information
Max. file size: 10 MB.
Please attach supporting information for the child's diagnosis here (for example last clinic letter).
Treatment Centre
(Required)
Consultant
(Required)
Stage of Surgery
(Required)
Siblings (including date of birth)
(Required)
Please provide, in full, the names, date of birth and gender of all siblings. Alternatively, state 'none'.
Do you have any other information to share?
Contact Preferences
Would you like to be put in touch with someone who has shared similar experiences?
(Required)
Yes
No
If you would like to receive updates about the work of LHM, including support & information, fundraising and awareness campaigns, please indicate below your methods of contact:
(Required)
Post
Email
Phone
I do not wish to be contacted
Where did you hear about us
(Required)
The Hospital told us
Word of mouth
Internet search
Facebook search
Other
Membership Terms
(Required)
I have read and agree to the
LHM Membership Terms & Conditions
MEMBERSHIP OF THE CHARITY REQUIRES AN OPEN AND HONEST SUBMISSION OF INFORMATION ON APPLICATION AND DURING THE TERM OF THE MEMBERSHIP
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