Join Us - National Cochlear Implant Users Association

APPLICATION FORM FOR MEMBERSHIP

I wish to apply for membership of the National Cochlear Implant Users Association for which I understand there is no charge at present.
I confirm that I am over the age of 18.

I give my consent for the Association to record my postal address details and my email address and for the Association to communicate with me by such means. The Association will hold this information in a secure database which will be used solely for these purposes, and which will not be made available to any third parties.

The General Data Protection Regulation (GDPR) require that my explicit consent to store my contact details is so recorded

Title: ……………………………………………………………….
First name or initial(s): …………………………………………………………………..

Surname …………………………………………………………………..

Full home address: …………………………………………………………………………………

…………………………………………………………………………………………

Post Code: …………………………………….

Email: ……………………………………………………………..

Signed: ………………………………………………… Dated: ……………………………………………

Although membership is free at the moment, we would be extremely grateful for any donation to help cover the costs of running the Association. If you are able to provide a donation please complete the following:

The amount (£…………) you wish to donate.

I wish to use the Gift Aid scheme for this donation – Yes/No

Please post this application form to:

Treasurer, NCIUA, 7, Eldridge Close, Dorchester, Dorset, DT1 2JS.