If you wish to join HeartLine, please fill in the membership form. You can either send it electronically by clicking submit, or print it out and post/fax it to the office.

About you
Full name(s)
Organisation (if applicable)
Postal Address
County/State
Postcode/Zip code
Country
Telephone (incl. Area Code)
Fax (incl. Area Code)
Email address
About your heart child
Name of heart child
Gender	Male    Female
Date of birth
Type of heart condition
Has your child had corrective surgery?	Yes     No
If so, at which hospital?
Did you receive a support pack when your child was in hospital?	Yes     No
Other children in your family
Name
Gender	Male    Female
Date of birth
Name
Gender	Male    Female
Date of birth
Name
Gender	Male    Female
Date of birth
Please tick all that apply: I'd like contact with local families I'm willing to support local families I'd like to receive the HeartLine magazine I'm a professional/organisation
How did you first hear about HeartLine? Surfing the Internet Congenital Heart Disease Web Ring Hospital Friend/Family Newspaper/Magazine TV/Radio Other (please detail below)
Any comments you wish to add Donation HeartLine Association does not charge a membership fee, but relies entirely on voluntary donations in order to support its members. We are grateful for any support you can give us.
Date