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Fields marked with a * are mandatory.

Your personal details Your Title

First Name*

Surname*

Billing Address (line 1)*

Billing Address (line 2)

Billing Address (line 3)

Billing Address (line 4)

Town*

County*

Postcode *

Country *

Day Phone

Email Address *

Date of birth

Full Membership Person with MND - no fee
Individual Membership - £12
Family Membership - £18
Reduced Rate - £6
Life Membership - £250
Overseas Membership ( additional £10 )

Associate Membership Organisational Membership - £25
Health & Social Care Professional - £12
Overseas Membership ( additional £10 )

Membership information

Please complete this section if you are taking up the Person with MND or Family Membership.

My family members are:

Name

Relationship

Date of birth

Could you tell us if you are:

a carer friend / relative of someone with MND.
His / her name is:

Associate membership information

Please complete this section if you are taking up the Associate Membership.

Some of our members have express a wish not to be mailed Thumb Print or not to be contacted by the local branch. Please tick if you would prefer:

Not to receive Thumb Print.
Not to be contacted by local branch.

From time to time we may write to you regarding developments about MND or to seek your support with financial appeals for our work. Please select one of the following boxes if you wish to receive:

All appeals Annual appeals only No appeals

The MND Association complies with the Data Protection Act. Your details will be added to our database. You may inform us at any time if you do not wish to receive mailings from the MND Association or the organizations with whom we co-operate.