Ordinary – Membership Application

Name

First

Last

Date Of Birth

Email

Phone

Password

Confirm Password

Please set your preferred password to enable your online account for charity

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What year did you become ill?

What age were you when you became ill?

What was your occupation (if applicable) when you became ill?

Do any other family members have M.E?

Yes
No

Have you been diagnosed with ME?

Yes
No

Are you virtually/entirely housebound

Yes
No

Are you Wheelchair User

Yes
No

Are you Bedbound

Yes
No

Have you ever used GET*?

Yes
No

Have you ever used CBT**?

Yes
No

A: The Contact List is a lengthy document sent to all ordinary members (including ordinary members outside of the EU) upon joining and contains personal member details for the purpose of encouraging communication between members. Inclusion in this list is entirely optional and ordinary members (and their carers – see next page) may opt in or out at any time by informing the Charity by post/email/telephone.

If you would like to be included in the Contact List, please complete this section. Please note, the permissions you give in below will appear on the Contact List.

A: ORDINARY MEMBER I would like to be included in the Contact List

Yes
No

B. If you are cared for by a family member/partner, their details may also be included in the Carers’ Section of the Contact List. If your carer would like to be included in this Section, please ask them to complete the section below and sign at the carer’s signature section on the next page

B: CARER I would like to be included in the Contact List

Yes
No

I severe like

Carer information is optional unless your carer has requested to be included in the contact list on the previous page, in which case their details are required. You may also choose to provide it voluntarily.

Carers Name

First

Last

Carers Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Carers Email

Carers Phone

Carers Date Of Birth

Enter Payment Details

Ordinary Membership (UK)

Price: £20.00

(NB. Ordinary Membership entitles you to receive by post a Contact List (and further updates to the list), two Newsletters per year and may include occasional additional mailings. You also have access to all Charity services as outlined in our Members Section of the Newsletter including our Advocacy Service.)

By signing, I wish to apply for ordinary membership of the 25% ME Group and confirm that the information I have provided in this application is accurate. I understand that this information may be used by the Charity for the purposes outlined in this Application Form and within the 25% ME Group’s Privacy Policy, which I have read and understood.xt with your own.

Members Signature

Clear Signature

Total

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Ordinary Membership (UK) 1 £20.00

Total £20.00