LHM Membership Form – Extended family member

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LHM Membership Form – Extended family member

Your Details

Your Name(Required)
Address(Required)

Child's Details

Heart Child's Name(Required)
Child's Date of Birth(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?
Are the parents of the child also members of LHM?

Contact Preferences

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)
Where did you hear about us(Required)
Membership Terms(Required)

MEMBERSHIP OF THE CHARITY REQUIRES AN OPEN AND HONEST SUBMISSION OF INFORMATION ON APPLICATION AND DURING THE TERM OF THE MEMBERSHIP