Membership Application Form 2011/2012
Name: ________________________________________________________
Address: ________________________________________________________
________________________________________________________
________________________________________________________
Home Phone No: _____________________________________________________
Mobile Phone No: ____________________________________________________
E-mail: ________________________________________________________
Date of Birth: ________________________________________________________
| I am a:- |
Please tick as appropriate |
| Survivor (Please complete next of kin and medical details overleaf) |
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| Carer |
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| HNNT Management Committee Member |
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| Healthcare Professional |
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| Supporter / other (please specify the nature of your interest below) |
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Applications will be considered by the Management Committee of Headway Newcastle & North Tyneside at the meeting following the submission of this form to the Secretary.
This form should be sent by post to:
Jane Pyrah
Headway Newcastle & North Tyneside
Freepost NEA 13812
Newcastle upon Tyne
NE2 1BR
Headway Newcastle and North Tyneside is a Registered Charity No 1142399 and a Company Limited by Guarantee Registered in England No. 7631747
NEXT OF KIN CONTACT DETAILS:
Name: _________________________________________________________
Contact No: _________________________________________________________
Relationship: _________________________________________________________
MEDICAL DETAILS:
Do you have any medical conditions of which we should be aware? (e.g. epilepsy)
_____________________________________________________________________
Dated:
.......................................................................................................................................
Signed
.......................................................................................................................................
PLEASE NOTE
- Membership will be subject to an annual Membership fee, currently £2.
- Membership is not transferable to anyone else.
- Membership of Headway Newcastle & North Tyneside constitutes agreement to comply with the rules, bye laws or other constitutional documents of the organisation. Copies of the constitutional documents are available upon request.
- Members must be aged 18 or over.
Headway Newcastle and North Tyneside is a Registered Charity No 1142399 and a Company Limited by Guarantee Registered in England No. 7631747
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