Plymouth Deaf Association Membership Form
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Full Name
*
Please enter your full legal name.
This field is required.
City/County
*
Enter your city or county.
This field is required.
Date of Birth
*
Enter your date of birth
dd/mm/yyyy
This field is required.
First Line of Address
*
Enter the first line of your address.
This field is required.
Postcode
*
Enter your postcode.
This field is required.
Phone Number
*
Enter your phone number including the area code.
This field is required.
Email
*
Enter a valid email address.
This field is required.
Emergency Contact Name
*
Enter the name of your emergency contact.
This field is required.
Emergency Contact Phone Number
*
Enter the emergency contact’s phone number including area code.
This field is required.
Membership Fee Payment Method
*
Select your payment method for the membership fee.
Cash
Bacs
Cheque
This field is required.
Date Joined
*
Enter the date you joined the association.
dd/mm/yyyy
This field is required.
GDPR Agreement
*
I agree that my personal information may be stored by the Plymouth Deaf Association.
This field is required.
Signature
*
Please provide your signature to confirm your agreement.
This field is required.
Date of Signature
*
Enter the date of your signature.
dd/mm/yyyy
This field is required.
Submit
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