Adult with a single ventricle heart – Registration Form Becoming a member of Little Hearts Matter could not be easier and is free to anyone seeking support and information because they are affected by a diagnosis of a single ventricle heart condition. Please fill in the form below and a member of our team will be in touch. Surname*First name*Address* Address Line 1 Address Line 2 Town/City ZIP / Postal Code Contact telephone numbers*Email address*If you do not have an email address, please specify NONE.Facebook NameYour date of birth* Date Format: DD slash MM slash YYYY Your genderFemaleMaleOtherWould rather not sayYour diagnosis*Please upload a copy of the first page of any clinic or hospital letter you have to confirm the diagnosis*Treatment centreConsultantStage of surgeryAre any relatives/family also members of LHM?YesNoDo you have a partner?YesNoDo you have any children?YesNoWould you like to be put in touch with someone who has had a similar experience?YesNoAny additional information* I have read and agree to the LHM Membership Terms and Conditions* MEMBERSHIP OF THE CHARITY REQUIRES AN OPEN AND HONEST SUBMISSION OF INFORMATION ON APPLICATION AND DURING THE TERM OF THE MEMBERSHIPContact*I would like to receive updates about the work of LHM, including support & information, fundraising and awareness campaigns. If so, please indicate below your preferred method of contact: Post Email Phone *WhiteMixedAsian or Asian BritishBlack or Black BritishChineseAny other ethnic backgroundBritishIrishTraveller of Irish HeritageGypsy/RomaAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed backgroundIndianPakistaniBangladeshiAny other Asian backgroundCaribbeanAfricanAny other Black background
