LHM Membership Form – Grandparent of a child with a single ventricle heart

Your Details

Your Name(Required)
Address(Required)
Some people use a different name on social media. Providing this will help us speed up your acceptance into our private groups.

Child's Details

Heart Child's Name(Required)
Child's Date of Birth / or due date(Required)
Child's Gender(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?
Please provide, in full, the names, date of birth and gender of all siblings. Alternatively, state 'none'.

Contact Preferences

Would you like to be put in touch with someone who has shared similar experiences?(Required)
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)
Membership Terms(Required)