LHM Membership Form – Parent who has lost a child because of complex congenital heart disease

Your Details

Your Name(Required)

First Last

Address(Required)

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

Email(Required)

Phone Number(Required)

Your ethnicity

Facebook profile name

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 and relationship to child

Child's name(Required)

Child's date of birth(Required)

Date your child passed away(Required)

Treatment Centre

What was your child's diagnosis?(Required)

Siblings(Required)

Please provide, in full, the names, date of birth and gender of all siblings. Alternatively, state 'none'.

Do you have any other information to share?

Contact Preferences

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

Yes

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 – Parent who has lost a child because of complex congenital heart disease

Your 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