CMPA Support Membership Application Form

WWW.CMPASUPPORT.ORG.UK
CMPA Support Membership Application Form
By completing and signing this form you are agreeing to the T&C’s Over the Page.
Personal Information:
Name:
Address:
Post Code:
Day Time Phone Number:
Evening Phone Number:
Mobile:
Email:
Preferred Method of Communication:
Email / Post
Your Family:
Number of Children Under 5
[ ]
Number of Children 5-11
[ ]
Number of Children 11-18
[ ]
Number of Adults
[ ]
What conditions affect your family, please tick all that apply:
IgE CMPA
IgE Wheat Allergy
Other IgE food Allergy*
Other non IgE food Allergy*
Coeliac Disease
FPIES
EGID
Environmental allergies i.e. “Hayfever”
Eczema
Non IgE Wheat Allergy
Asthma
Non IgE CMPA
IgE Soya Allergy
Non IgE Soya Allergy
IgE Egg Allergy
Non IgE Egg Allergy
*Please provide details of other allergies:
How did you hear about CMPA Support?
Are you interested in becoming a member of the CMPA Support Children’s Allergy Foundation
Committee or volunteering?
We look forward to receiving your application and we will ensure that any information you have provided about
yourself or others will be treated as confidential. Your details will be kept on our database. We will not hand your
information to any other organisation.
Signature:
Date:
Once completed please return this form with a cheque or postal order for £10 payable to CMPA Support to:
Membership, CMPA Support, 5 Cypress Grove, School Aycliffe, Co Durham, DL5 6GP
WWW.CMPASUPPORT.ORG.UK
[email protected]
WWW.CMPASUPPORT.ORG.UK
Terms & Conditions
1) CMPA Support Membership is open to residents of the United Kingdom of England, Scotland, Wales and
Northern Ireland only.
2) Membership will be granted upon receipt of a completed membership application form and fees in the form of
a cheque or postal order payable to CMPA Support for £10.00 (2015)
3) Membership must be renewed and paid for on an annual basis and can be renewed as soon as you receive
your renewal reminder via your preferred contact method as stated in your application.
4) All application forms and any other correspondence must be sent to: Membership, CMPA Support, 5 Cypress
Grove, School Aycliffe, Co Durham, DL5 6GP
5) Please allow up to 6 weeks for delivery of membership packs.
Membership Benefits*:
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Members are invited to join the exclusive member’s only CMPA Support Facebook Group and website forum.
CMPA Support pin badge.
Monthly newsletter.
FSA Allergen alert updates.
*Members will receive a quarterly Magazine filled with special offers, coupons, recipes, information and
support!
*A membership card which entitles the barer to exclusive member offers including free entry to CMPA
Support Play Groups.
ICE cards.
Chef Cards.
Translation Cards for trips abroad.
Ingredient avoidance cards for each allergen affecting the family.
Copy of our annual charity report.
Right to apply to join the committee, attend the charity AGM and volunteer for the charity.
*Some of the benefits mentioned above will only become available when enough members have joined CMPA
Support. The benefits are provided by third parties once a certain number of members join.
CMPA Support groups are only available in selected towns and cities at this time, more will become available as the
foundation grows and more funds are raised.
WWW.CMPASUPPORT.ORG.UK
[email protected]