Address:  208 Tur Uisce, Doughiska, Galway city Web: www.me-ireland.com  Email: info@me-ireland.com   Phone:  085 8231371   Charity number: being processed by government authority  

Membership Form

(Print out Form and fill it in)


Name of individual / group in Block capitals

_____________________________________________________________________________


ADDRESS_____________________________________________________________________________

______________________________________________________________________________________

TELEPHONE NO: _____________________________________________

EMAIL:  _____________________________________________

Tick if you are 18 or over

Male               Female


Year you became disabled with M.E.

______________________________


Severity of Illness (tick boxes)

Housebound
Bedbound
Use a wheelchair
Use a walking aid
In Hospital .
Severerely affected
Moderately affected
Mildly affected
        

Any treatments you found effective or useful

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

Would you be willing to set up a local support group to work for a national ME clinic ?

Yes               No


Would you like your phone number or email shared with others interested in forming or running a local support group ?

Phone number         Yes               No
Email        Yes               No


I agree to become a member of Campaign for a National ME Clinic and to support its Aims and Objectives.

Signature: ___________________________________   Date: ________________________


Campaign for a National ME Clinic complies with Data Protection Acts 1988, 2003.


Mailing Address

National Headquarters

Campaign for a National ME Clinic

208 Tur Uisce

Doughiska

Galway city

Ireland