Cystinosis Foundation UK
Membership Form – Supporters
Name
Family Name : ………………………………………………………………
Christian Names : ………………………………………………………………
Address Details
House
/ Street : ………………………………………………………………
Town 1 : ………………………………………………………………
Town 2 : ………………………………………………………………
County : ………………………………………………………………
Post code : ………………………………………………………………
Contact Details
Telephone : ………………………………………………………………
E-Mail : ………………………………………………………………
Additional Information (at your discretion)
Are you related to a cystinosis patient (Y/N)? ……………………………
If ‘Y’, to whom are you related? ……………………………………………
What is your relationship to that person? …………………………………
We thank you for taking the time to complete this form
and for making the enclosed donation.
.
Any information published by the Cystinosis Foundation UK, or information
published by other sources
and distributed by the Cystinosis Foundation UK is for general information
purposes only and
should not be construed as advising on diagnosis or treatment of any condition.