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.
Please attach supporting information for the child's diagnosis here (for example last clinic letter).
Please provide, in full, the names, date of birth and gender of all siblings. Alternatively, state 'none'.
Where did you hear about us(Required)

Contact Consent

By completing this form, you understand that we may contact you about your membership, support services, fundraising activities you are involved in, and other information necessary to administer your relationship with Little Hearts Matter. Please see our full Membership Terms and Conditions here: LHM Membership Terms & Conditions
We may also contact you by email or SMS about fundraising campaigns, events, appeals, and other ways to support Little Hearts Matter. If you would prefer not to receive fundraising communications by email or SMS, please tick below:
You can update your communication preferences or opt out at any time by contacting info@lhm.org.uk

Contact Preferences

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

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