Parent who has lost a child because of complex congenital heart disease – 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.Child's name*Child's date of birth* Date your child passed away* Partner's nameSiblings01234MoreSibling 1 nameSibling 1 date of birth Sibling 2 nameSibling 2 date of birth Sibling 3 nameSibling 3 date of birth Sibling 4 nameSibling 4 date of birth Other siblings' names and dates of birthTreatment centreWhat was your child's diagnosis?*Would you like to be put in touch with someone who has had a similar experience?YesNoAny additional informationContact*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: Post Email Phone * I have read and agree to the LHM Membership Terms and Conditions* Little Hearts Matter members come from many walks of life and from many different backgrounds. We offer our support to anyone who contacts us and we hope we can find information for anyone, from any background, seeking our help. As the charity grows, we and our funders would like to be able to gain a greater understanding of our appeal within different ethnic groups living in the UK. It is not compulsory but we would be grateful if you would complete this final section of the application form to help us gain a greater understanding of our members’ needs. Thank you.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 This iframe contains the logic required to handle AJAX powered Gravity Forms.