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BECOME A MEMBER
LHM Membership – Moving from Youth to SVH Adult services
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LHM Membership – Moving from Youth to SVH Adult services
LHM Membership Form - Moving from Youth to Adult services
Your Details
Your Name
(Required)
First
Last
Your Date of Birth
(Required)
Day
Month
Year
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Email
(Required)
Phone Number
(Required)
Your ethnicity
White
Mixed
Asian or Asian British
Black or Black British
Chinese
Any other ethnic background
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.
Gender
(Required)
Male
Female
Other
Prefer not to say
Your Diagnosis
(Required)
Please give as much detail as possible here. If you are unsure about the diagnosis, what has your doctor / consultant said?
Please upload a copy of the first page of any clinic or hospital letter you have to confirm the diagnosis*
(Required)
Max. file size: 10 MB.
Treatment Centre
(Required)
Consultant
(Required)
Stage of Surgery
(Required)
Are any relatives/family also members of LHM?
Yes
No
Do you have any children?
Yes
No
Do you have a partner who also wishes to join LHM?
Yes
No
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
Awareness
Contact us
Support
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