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How to join the group or change your details

If you'd like to join the group here and now, fill in the form below.   Please fill in as many boxes as you can.  If you are already a member you may use the form to update your details. For security reasons we cannot display your present details.  Again, please fill as many boxes as you can. 

Remember, membership is free, but donations are welcome in any currency.

The LCG welcomes applications for membership from all countries but is focussed predominantly in the UK and Ireland. Families in North America are advised to contact the Lissencephaly Network (http://www.lissencephaly.org) in the first instance.

NEW APPLICATION OR CHANGE DETAILS

New Application       Change Details (fill in all boxes)

ABOUT YOU

Your Name                 

Your Address             

Post Code                  

Country                        

Telephone Number    

Your Email Address   

 

ABOUT YOUR CHILD

Child's Full Name      

Child's Date of Birth (dd/mm/yyyy)

Child's sex  

Child's Diagnosis     

Relationship to You  

Any questions you would like to ask about the LCG

  

    

Periodically the group publishes it's newletter with details of other families, purely so you are able to contact each other.   This information is for group members only and is not distributed to any other individual or organisation.  Would you be willing to have your name, address, telephone number and child's details published in the group's newsletter? 

Before submitting the information above, please ensure that you have entered all your details correctly.  If you have not included an email address, we may not be able to contact you.

The LCG welcomes applications for membership from all countries but is focussed predominantly in the UK and Ireland.  Families in North America are advised to contact the Lissencephaly Network (http://www.lissencephaly.org) in the first instance.

   

The LCG is registered under the Data Protection Act (ref: X4062169)

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