The
Cardiomyopathy
Association

Membership Form

Becoming a member of the CMA entitles you to access advice on the condition, receive copies of regular newsletters and benefit from the CMA's support network. If you wish to join, please print and return the form below with a cheque made payable to the 'Cardiomyopathy Association'.

I would like to become a member of the association and enclose £12 (UK) £15 (Europe) £25 (World) (delete as appropriate) to cover the annual subscription renewable annually: [__] please tick

I enclose a donation to the Cardiomyopathy Association together with this form.

£ ______________________

I am a UK Tax payer and want the charity to reclaim tax on donations [__] please tick

Payment can be made by Credit Card or by cheque (made payable to the Cardiomyopathy Association)

Card no: [__] [__] [__] [__]   [__] [__] [__] [__]   [__] [__] [__] [__]   [__] [__] [__] [__]

3 digit security code:  [__] [__] [__]

Expiry ____/____       Start ____/____

Type of card:______________________________

Mr/Mrs/Miss/Ms (circle as appropriate)

Surname    ______________________

First Name ______________________

Address    ______________________________________

______________________________________________

______________________________________

Post code       ___________________________

Email address __________________________

Date of Birth   ____/____/________

Tel No      __________________________

Please indicate which of the following conditions applies
to your application:

Dilated cardiomyopathy _____

Hypertrophic cardiomyopathy _____

Arryhythmogenic right ventricular cardiomyopathy _____

Restrictive cardiomyopathy _____

Other ___________________

Please print this form and send it to:

Cardiomyopathy Association, Unit 10, Chiltern Court, Asheridge Road, Chesham, Bucks, HP5 2PX

Alternatively print and fax this form to:

01494 797199

If you would like to make a donation, please visit our Donations Page.

If you are interested in any of the following, please circle

a) Fundraising / assisting

b) Support group meetings

c) Media work

d) Other

Dedicated to Damian McLoughlin, who died age 20 of cardiomyopathy. This site is supported by Damian's family and friends.