LHM Membership Form – Extended family member

Your Details

Your Name(Required)

First Last

Your relationship to child(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Phone Number(Required)

Your ethnicity

Child's Details

Heart Child's Name(Required)

First Last

Child's Date of Birth(Required)

Child's Diagnosis(Required)

Please give as much detail as possible here. If you are unsure about the diagnosis, what has your doctor / consultant said about future treatment?

Are the parents of the child also members of LHM?

Yes

Do you have any other information to share?

Contact Preferences

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:(Required)

Post

Phone

I do not wish to be contacted

LHM Membership Form – Extended family member

Your Details

Child's Details

Contact Preferences

MEMBERSHIP OF THE CHARITY REQUIRES AN OPEN AND HONEST SUBMISSION OF INFORMATION ON APPLICATION AND DURING THE TERM OF THE MEMBERSHIP

Main office