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

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LHM Membership Form – Parent 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.
Your Partners full name (If no details please put n/a)(Required)
If the address is the same as above please tick box, if different please fill out address information below (if no details available please tick "Same as above" box)
Address
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(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?
Max. file size: 10 MB.
If you have supporting information for the child's diagnosis, attach it here.
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)
Where did you hear about us(Required)
Membership Terms(Required)

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