Parent of a child with a single ventricle heart - Little Hearts Matter

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Become a member / Parent of a child with a single ventricle heart

Parent of a child 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.

Personal Details
Surname*
First name*
Address*
Address Line 1 Address Line 2 Town/City ZIP / Postal Code
Relationship to child*
Contact telephone numbers*
Email address*

If you do not have an email address, please specify NONE.
Facebook Profile Name

This will enable us to identify Closed Facebook page requests quicker. If you do not have a Facebook account, please specify NONE.
Partner's name
Relationship to child
Email address

If you do not have an email address, please specify NONE
Facebook Profile Name

This will enable us to identify Closed Facebook page requests quicker. If you do not have a Facebook account, please specify NONE.
Child's Details
Heart child's name*
Child's date of birth*
DD slash MM slash YYYY
Child's gender*
- Female
- Male
Child's diagnosis*
Treatment centre*
Consultant
Stage of surgery*
Siblings' Details
Siblings
Sibling 1 name
Gender
Sibling 1 date of birth
DD slash MM slash YYYY
Sibling 2 name
Gender
Sibling 2 date of birth
DD slash MM slash YYYY
Sibling 3 name
Gender
Sibling 3 date of birth
DD slash MM slash YYYY
Sibling 4 name
Gender
Sibling 4 date of birth
DD slash MM slash YYYY
Other siblings' names and dates of birth
Contact Preferences
Would you like to be put in touch with someone who has had a similar experience?
- Yes
- No
Any additional information
Contact*
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*
MEMBERSHIP OF THE CHARITY REQUIRES AN OPEN AND HONEST SUBMISSION OF INFORMATION ON APPLICATION AND DURING THE TERM OF THE MEMBERSHIP
- White
- Mixed
- Asian or Asian British
- Black or Black British
- Chinese
- Any other ethnic background

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Parent of a child with a single ventricle heart
Parent expecting a child with a single ventricle heart
Parent who has lost a child because of complex congenital heart disease
Grandparent, or expectant grandparent, of a child with a single ventricle heart
Adult with a single ventricle heart
Young person with a single ventricle heart, under the age of 18 years .
Extended family member
Health professional
Education professional
Social service professional
Friend of the charity

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The LHM office will be closed from the 23rd to the 30th December, but our members can still contact us if they need a chat.📱 0121 455 8982📧 [email protected] ❤️Or drop us a private message ... See MoreSee Less

1 month ago ·

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💬 Charlie is loving Christmas this year and is excited for Santa to visit!💬With Charlie’s Fontan operation likely to happen in the Spring next year we are enjoying every precious moment as a family this Christmas.❤ ... See MoreSee Less

1 month ago ·

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