MEMBERSHIP APPLICATION
Please print this form and send it to the address below to receive a membership pack.
Mr./ Mrs./ Miss / Ms. FIRST NAME.................. SURNAME....................
ADDRESS........................................................................
...............................................................................
POST CODE..................................
COUNTRY.................................... DATE OF BIRTH......................
TELEPHONE (Home)........................ (Work).............................
[ ] I have lymphoedema
[ ] I am a Health Care Professional
[ ] Other (please specify)
Membership Fee £15 (Overseas £30) £...........
Donation £...........
Total Amount Enclosed £...........
Please make your cheque, in Pounds Sterling only, payable to the
Lymphoedema Support Network
write your name and address on the back and return with this form to:
LSN, St.Luke's Crypt, Sydney Street, LONDON, SW3 6NH, UK
Please also include an A4 self-addressed envelope
Registered Charity No.1018749
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