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IRISH KIDNEY ASSOCIATION CLG
                                       (Company Limited By Guarantee)
                    MEMBERSHIP APPLICATION FORM


                                            BLOCK CAPITAL LETTERS PLEASE:

        Mr.       Mrs.      Ms.         FIRST NAME:                                                        INITIAL:


        SURNAME:

        ADDRESS:


        POSTCODE:                                         TEL:                    MOBILE:

        EMAIL:



        ARE YOU A KIDNEY PATIENT:            IF YES                         IF NO
        If yes, please indicate your current
                                                                             PRE DIALYSIS           RELATIVE OF PATIENT
        patient status. Please update our
        records when/if status changes.
                                                                             HAEMODIALYSIS           FRIEND OF PATIENT
                                                                             APD           GENERAL INTEREST

                                                                             CAPD
                                                                             TRANSPLANT


        HOSPITAL OR DIALYSIS CLINIC YOU ARE ATTENDING:

        YOU MUST BE 18 YEARS OF AGE, OR OLDER, TO BECOME A MEMBER OF THE ASSOCIATION

        AS A MEMBER YOU WILL AUTOMATICALLY RECEIVE OUR QUARTERLY ‘SUPPORT’ MAGAZINE BY POST, UNLESS
        THERE IS ALREADY ANOTHER ASSOCIATION MEMBER AT YOUR ADDRESS RECEIVING IT?

        I WOULD PREFER TO RECEIVE AN EMAIL LINK TO THE MAGAZINE EACH QUARTER INSTEAD                   YES


        CAN WE CORRESPOND WITH YOU BY EMAIL (if you have an email address), IN PARTICULAR NOTICES
        RE: ANNUAL GENERAL MEETING OF THE ASSOCIATION AND ANNUAL DIRECTOR’S REPORT, ETC.

                                                                                 YES            NO

        WOULD YOU LIKE CORRESPONDENCE FROM THE LOCAL BRANCH WITHIN YOUR AREA?


                                                                                 YES            NO

        WOULD YOU LIKE CORRESPONDENCE FROM THE SPORTS SECTION OF THE IKA?

                                                                                 YES            NO

        TO BECOME A VOTING MEMBER OF THE ASSOCIATION YOU MUST SUBSCRIBE TO THE CONSTITUTION OF THE
        ASSOCIATION (copy available on request) OR ON THE IKA WEBSITE - www.ika.ie

        I SUBSCRIBE TO (sign up to and accept) THE CONSTITUTION OF THE IRISH KIDNEY ASSOCIATION CLG (Company
        Limited by Guarantee).



        SIGNATURE:                                                                                 DATE:

                                    Please return the completed, signed form to the
               Irish Kidney Association CLG, (Freepost), Donor House, Block 43A, Park West, D12, P5V6.
                                               There is no subscription charge.
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