Ataxia UK NW London Branch Membership Joining Form

Choose one(required)

Mr

Mrs

Miss

Ms

Dr

Other

If other, please state

First Name(required)

Last Name(required)

Full Address, including postcode(required)

Telephone Number(required)

Email(required)

Are you a current Friend (member) of Ataxia UK?(required)

No

Yes

What is your connection with ataxia? (select all that apply)(required)

I have ataxia

Other members of my family or some of my relatives have ataxia

I have a friend who has ataxia

Other (please specify)

Other

In order to promote our branch photos and/or Zoom recordings may be made at our events. If you are in any photos or Zoom recordings may we have your permisssion to use them?(required)

No

Yes

By submitting this form you will be agreeing to your contact details being held by the North West London Branch of Ataxia UK and you will receive communications from the Branch. In addition you have the option of becoming a Friend (member) of Ataxia UK.

If you are not already a Friend (member) of Ataxia UK, would you like to become a Friend (member) of Ataxia UK and receive communications from them?

No

Yes

Submit

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