HEADWAY NORTH LONDON

Membership Form

improvinglife after brain injury

As a Member supporter of Headway North London (HNL) you will have access to our range of services and will receive notification of monthly meetings, social events and other activities*. (*there may be additional costs payable)

It is important that this form is completed and returned to us for our records.

It is your group you make it what it is

Contact Information

Name
Address
Post Code:
London Borough of:
Home Phone:
Mobile Phone:
Email address:

Personal Details

Date of Birth:__
We are now required to declare our members’ ethnic backgrounds. Please indicate which of the following best describes you:
White (British/Irish/other) / Asian (Indian/Pakistani/Bangladeshi/other)
Black (Caribbean/African) / Mixed Ethnicity
Chinese / Prefer Not to Answer
Other (please specify)
Which of the following best describes you? (tick those that apply)
Brain Injury Survivor / Professional Supporter / Carer or Relative / Other
How were you injured?
Road Traffic Incident / Stroke Violence Sports Industrial
Virus Hemorrhage Tumour Other (please specify) Slip down steps
About your brain injury,
What year were you injured?
Were you in a coma? / ______
If so how longfor? 21 days / Did you have Surgery?Yes No
How long in Hospital? 7 weeks

Medical / Injury Information

GP Name
GP Address
GP Contact Number:

Your Voice

Would you be interested in talking to the media/newspaper/TV/magazines/radio about your story? Yes No
Are you already a Member of Headway UK the brain injury association? Yes No

Would you like to receive information on some of our regular services?

3rd Wed Support Meeting Peer SupportGroup Computer suite & Drop-in-service Activities Carer Support Buddy Scheme Outings Other
Is there a subject or topic you would like to know about at the monthly meeting, or a service or activity you would like to take part in? Do let us know as this helps with developing our services.
If so what ?
I enclose my Annual Membership Fee:
Individual 1 year £20 [ ] Individual Professional 1 year £50 [ ]
Corporate 1 year £120 [ ]
Corporate 3 years £300 [ ]
Cheque made payable to: Headway North London [ ]
Or
Direct Payment to CAF Bank, Sort code 40-52-40, a/c 00019312 [ ]
Please use the reference SUB[Your name]
If you do not wish to receive any information by post or email, please tick this box [ ]
If you wish to make an additional donation this would be appreciated in supporting the services and activities we provide.
[ ] I enclose a donation of £…………………………………………Please tell us if you need a Gift Aid form [ ]
[ ] Would you like information about standing orderpayments

Please return completed form and your payment to:

Headway North London,

Membership Secretary,

Headway North London

c/o Jill Greenfield Partner

Field Fisher Solicitors

Riverbank House

2 Swan Lane

London EC4R 3TT