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Supporting people affected by Charcot-Marie-Tooth disease.

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When completing this form, you are giving your consent for Charcot-Marie-Tooth UK to store this information on our database, for the purposes of administering our membership scheme.   If you would like any further information about our privacy policy, please click here, or phone 01202 474203.

We are committed to keeping your personal information private and NEVER share your data with any outside parties.

Title
First Name
Last Name
Email
Address line 1
Address line 2
Address line 3
City/Town
County
Are you outside the UK
Postcode
Country
Telephone
Mobile
Date of birth
I would like to receive the magazine by;
   
You will also automatically be subscribed to our e-newsletter - you can unsubscribe at any time.
   
I am:
A person with CMT
Type of CMT
A Family member/friend of someone with CMT
Health or social care professional
Other interested person

 

If you have children, with or without CMT, it helps us to tailor our services. Please be assured that this information is NEVER shared outside of CMT UK.

First name Last name DOB CMT
1
2
3
4

 

Year of diagnosis   
   
What is your ethnic group?
   
Would you like to be in touch with the nearest local group to you, (if there is one)? If you consent to this, your basic contact details (address, email, telephone) may be shared with our authorised group leaders.
   
I want Charcot-Marie-Tooth UK to treat my donations and subscriptions as Gift Aid donations.
I confirm that I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6th April to 5th April) that is at least equal to the amount of tax that all charities that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand the charity will reclaim 25p of tax on every £1 that I have given
Gift Aid Declaration
   
Would you like to becaome a member of the Facebook group for CMT UK. This is our replacement to the forum and is a closed group for paying members only.
Facebook Group

 

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