Membership Form

    

First Name :

 

Surname :

 

Address :

 

Postcode :

 

Tel No :

 

Fax No :

 

Mobile No :

 

Textphone No :

 

Email :

 

   

Do you have any special needs for meeting? E.g. access,. loop, signer, speech to text? Please specify!

 
 

The following questions help us with funding applications to help us provide the communcation equipment our group needs, hire of premise etc.

Your Local Health Authority:

 

Make & Model of implant:

 

Year:

  

   

Are you: (Please select!)

I have a CI

My Child has a CI

 
 

I am thinking about having an implant

I am a family or friend of an implantee

 
  Other Reasons: I am waiting for a CI  
     

Membership Fee

Individuals £10 per year Couples £12 per year
Families £15 per year
Corporate £20 per year