New Membership Application Form

We take the protection of the data we hold about you as a local branch member/attendee seriously. We will do everything possible to ensure that data is collected, stored, processed, maintained and retained following current and future UK data protection legislation. Please read the full privacy notice on the Parkinson’s UK website at parkinsons.org.uk/privacy to see how we will treat the personal information that you provide us. Thank you for supporting Parkinson’s UK and your local branch. Please complete and return this form by post to our Membership Secretary: Mr Keith Black, 32 Oakland Avenue, Farnham, GU9 9DX.

Join Guildford Parkinson’s Branch

* indicates required

Email Address *     <p>Please enter an email address to which we can send material

Principal Role *Diagnosed MemberCarer / SupporterSupplierNHSOther            Knowing you helps us to offer more targetted support </p>

First Name *

Last Name *

1st Line Address 1st Line of address e.g. 8 Primrose Gardens

2nd Line Address 2nd Line of address e.g. Merrow

Postal Town Post Town e.g. GUILDFORD

Postcode Postcode e.g. GU4 7BQ

Phone Number Contact number e.g 01483 123456 or 07123 456789

I’d like to be involved with…..

• Exercise Class – Foundation Physio
• Exercise Class – Surrey Hills Rehab
• Parkinsong
• Loud and Clear Voice Maintenance
• Newly Diagnosed Support Group
• Friendship Group
• Carers Support Group
• Parkinson Dance
• Seated Yoga
• Pilates
• Tuesday Afternoon Social Meeting

Permission to use photos in publicity campaigns YesNo  We can use photos of you in our literature.

Share with PD-UK YesNo Can we share membership data with PD-UK

Contact me about a donation YesNo I’d like to receive information about making a donation

Comms Preference

• Paper
• Digital

Date profile was reviewed and updated *

/ / (dd / mm / yyyy)

Enter today’s date to indicate you have reviewed your details

Email Format

• html
• text