Patient and Carer Forum Joining Form

Please note that all fields preceded by text followed by a * are mandatory.

Contact details
	Title: *	or
	Forename(s): *
	Surname: *
	Date of Birth:
	Address - 1st line *
	2nd line
	3rd line
	Town/city
	Postcode
	Country
	Telephone number:
	Mobile number:
	E-mail address: *
How would you prefer to receive information from the COPD project?
	*	or
	I am: *	or
	When were you / the person you care for diagnosed with COPD? *	or
	Are you a member of a Breathe Easy group? *
	If yes, which one?
	Do you sit on any hospital or PCT boards? *
	If yes, which:
	Are you a member of the British Lung Foundation? *
	Where did you hear about the Patient and Carer Forum? (If other please state)	or
Data Protection Act 1998
	We may, from time to time, allow certain other charities to contact you. If you would prefer not to receive these communications, please tick here.