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 Membership Form

Please complete the form below for membership to The Children’s Mitochondrial Disease Network. Forward your membership money by post to the address given below. Membership Form Registered Charity No. 1070533

Part A & D To be completed by all

Surname
Forenames
Title: Mr, Mrs, Miss, Ms, Dr, Prof 
Address 
Postcode 
Telephone
Fax
E mail
Website

Part B. Parents, Carers, Grandparents, Individuals (Optional)
Child’s / Individual: Name; *d.o.b & *d.o.d, (*optional if applicable) 
Mitochondrial Condition
Where & When Diagnosed, (optional)
Current Treatments, (Optional) 
Particular Problems, Medical & Non-medical, you would like addressed, (Optional), Surgical Advice, Feeding, Equipment etc.

Part C. Professional’s, Dr.’s, Scientists, Groups, Others
Your Professional Title & Particular Interest
Would you consider preparing an article for general readership and attending a family conference as a speaker?
Please indicate, other ideas and suggestions, you feel would benefit members, our colleagues, families & useful publications, etc.


Part. D. Membership Fees & Date Protection:
 All information is treated with total confidentiality, only information you wished to be passed on to other members of The Children’s Mitochondrial Disease Network, will be forwarded.

Membership of "EMDN" is Free for Parents, Carers & Professionals but the membership form must be completed & either submitted by e mail or sent by post.


Please make all cheques & monies payable to “EMDN” in £’s Sterling.

Send to:
MAYFIELD HOUSE 
30 Heber Walk
Chester Way
Northwich
CW9 5JB
England
UK

CMDN Bankers:
Loyds TSB Northwich
Acc Name: "CMDN"
Acc No: 35157268
Sort Code: 77 46 09