MS Action Membership.
We encourage people to self manage their condition in order for them to live as independent a life as possible. This is attained by using the highest standard of therapies and treatments that are appropriate to suit the individual needs of the sufferer. We operate a six day open door policy and offer a place of sanctuary to all disabled people.
If you would like to become a Member please complete the Member's Agreement and Guarantee Section below.
Members Agreement and Guarantee.
I agree to become a Member of MS Action. Should the company be wound up I promise to pay the sum of £1:00 towards its debts if asked to do so. I acknowledge that acceptance of my application is on the express understanding that no previous application by me has been refused.
Please Use Black or Blue Pen to Complete Form and Print Answers Clearly.
Title; _____ First Name;____________________ Surname; _________________________
Information about the person taking the therapy if different from above.
Address: _________________________________________________________________________
_________________________________________________________________________________
Borough; _________________________ Post Code; ___________________
Telephone Numbers;
Home; ____________________ Work; ____________________ Mobile; ____________________
Email Address: ..............................................
Date of Birth; ________/________/________ SEX; Male / Female
Disability; ________________________________________________________________________
Date of diagnosis; ________/________/________
Medication; ______________________________________________________________________
_________________________________________________________________________________
Ethnic Origin; (please tick appropriate status)
Asian[_] Black[_] Chinese[_] Mixed[_] White[_] Other[_] please state; _________________
Doctor's Details;
Doctors Name; ____________________________________
Address; ___________________________________________________________________
________________________________________________ Post Code; _________________
Alternate Contact Details; (in the case of an emergency);
Name; ___________________________________________________________________________
Address; _________________________________________________________________________
_______________________________________________ Post Code; __________________
Telephone Number (including the dialing code); _____________________________________
Signed; ____________________________________ Date; ________/________/________
Annual Membership Fees - please tick the appropriate one that applies for you.
Individual Memebership; £25:00 [_] Member + 1; £30:00 [_]
Income Support; £12:50 [_] I.S. Member + 1; £15:00 [_]
MS Action is a charity - so any donation would be very helpful and greatly appreciated.
If you wish to make a donation please tick a the box that matches your gift.
[_] £5:00 [_] £10:00 [_] £50:00 [_] £100:00 [_] Other Amount please specify £ ________:____
Thank you for your support.
Unit 17 Waltham Park Way, Billet Road, Walthamstow, London E.17 5DU
Telephone & Fax 020 8531 9216
Registered Company No. 21366411
Registered Charity No. 803187
Established 1984