LHM Membership Form – Young person with a single ventricle heart

  1. Home /
  2. LHM Membership Form – Young person with a single ventricle heart

LHM Membership Form – Young person with a single ventricle heart

LHM Youth Zone membership: Young Person with a single ventricle heart, ages 11 - 18

Bear in mind guys that if you're under 18 years your parents/carers need to be members too.

Your Details

Your Name(Required)
Your Date of Birth(Required)
Address(Required)
Gender(Required)
Please give as much detail as possible here. If you are unsure about the diagnosis, what has your doctor / consultant said?
Max. file size: 10 MB.
Are your parents also members of LHM?(Required)

Contact Preferences

Would you like to be put in touch with someone who has shared similar experiences?(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