Membership Form for Support Group
I would like to be a part of a support group. Please keep me informed about the meetings and other activities.

Type of Member (please specify):
Patient/ Patient’s Family Member (Specify name of patient and relationship in the space provided)

           
 
Name* [full name]
Type of Member (please specify)
Age
Address
City
Country
Pin
Phone - - ( country code-city code-phone number)
E-Mail*

(Kindly fill in the following details if you are a Patient)

Diagnosis

Treatment Received
No: of years on Follow up

(Kindly fill in the following details if you are Patient’s Family Member)
Please specify reason for joining a support group from the options given below:

Requiring support to cope with illness

Volunteer
Other (Please specify reason)
* - Mandatory Fields