Membership Application Form

Page 1 of 3

SECTION 1: CONTACT DETAILS:

Contact details of the person paying the membership fee. All fields marked with a * are required.

Title*

Forename*

Surname*

Sex*

Male

Female

Address and Postcode*

Date of Birth*

Tel (Daytime)*

Tel (Evening)*

Email*

Do you have scoliosis?*

Yes

Are you a relative / carer of someone with scoliosis?*

Yes

Please complete Section 1a if you have answered ‘Yes’ to the question above.

If your answer was 'No' please move on to Section 2 on the following page

If you answered ‘No’ to both questions above please go to Section 3.

SECTION 1a: CONTACT DETAILS:

Contact details of the person with scoliosis

Relationship to fee payer

Full name

Sex

Male

Female

Date of birth

Address (if different from above)

Tel (Daytime)

Tel (Evening)