A little Poorly- Brighton
Membership Form
Full Name
*
First Name
Last Name
Please provide a brief list of your diagnosis’ including any allergies we may need to be aware of for meet ups.
Address
*
House Number
Address Line two
Town or City
County
Post Code
Phone Number
*
-
Phone Number
E-mail
We aim to communicate via email address with regards to up coming meet ups.
Next of Kin Contact Details
First Name
Last Name
Next of Kin Phone Number
-
Phone Number
Are you a member of our Facebook group?
*
Please Select
Yes
No
Joining Now
What are your hobbies and interests?
Arts, music? Anything in particular!
What do you hope to gain from joining ‘ A little Poorly- Brighton’
Do you aim to make friends, socialise, learn new skills, interact in person or online?
Signature
Clear
By Signing the Above box you agree to abide by all group rules which will be available to read on the Facebook page & available via email upon request.
Write ‘I agree’
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