I/We wish to become a member of Aid for Children with Tracheostomies
(also known as ACT).
Parents/Carer’s FULL Names:
POSTAL ADDRESS:
COUNTY:
POSTCODE:
TELEPHONE:
EMAIL:
CHILD’S FULL NAME:
CHILD'S DATE OF BIRTH:
REASON FOR TRACHEOSTOMY:
ANY OTHER ASSOCIATED MEDICAL CONDITIONS/SYNDROMES:
.
NAME & ADDRESS OF HOSPITAL(S) DEALING WITH YOUR CHILD:
IS YOUR CHILD VENTILATED: NO
/YES
–DAY & NIGHT
/NIGHT TIME
ONLY
(PLEASE INDICATE)
ALL THIS INFORMATION IS FOR OUR DATABASE. IT WILL BE KEPT CONFIDENTIAL.
However, because we are a Support Group we often receive requests from
members asking to be put in touch with other parents who may live in
their area, or who perhaps may have a child with a similar medical
condition. These introductions generally result in mutual support or
the exchange of useful information.
CONFIDENTIALITY WAVER – Please delete the statement that does
not apply
I CONSENT TO SOME OR ALL OF MY DETAILS BEING PASSED
TO ANOTHER MEMBER
I REQUEST THAT NONE OF MY DETAILS ARE MADE KNOWN
Please process my application for Membership.
Signed:
Dated:
