CYP Membership

First Name*

Surname*

Date of Birth*

Telephone number*

Mobile number

Email*

Address line 1*

Address line 2

Address line 3

Town/City*

County*

Postcode*

Would you describe yourself as severely affected?*

IF YOU ARE UNDER 16

Please provide your Parent/Carer/Guardian’s FULL NAME

Please provide your Parent/Carer/Guardian’s Email

Please provide your Parent/Carer/Guardian’s Phone Number

IF YOU ARE 16 AND OVER

I give consent for Action for M.E. to process my data.

I give consent to be contacted by telephone

I give consent to be contacted by email

I give consent to be contacted by SMS

I give consent to be contacted by Letter

Gender

Ethnic Group

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