MRSA Action UK
Membership Form
Registered Charity No. 1115672

You can help just by giving an annual subscription of £10, or you may
wish to help by distributing leaflets, or in some other way, we are all
volunteers helping to raise awareness and provide support to those
affected by healthcare infections, join us today.  The information provided
will be treated in the strictest confidence.

I wish to become a member of MRSA Action UK

Name. …………………………………………………............
DOB. ………………............................................................
Address. ……………………………………………….............
…………………………………………………………............
……………………………………………………………........
Postcode…………..........................................................…..

Gender: Male. / Female

Do you consider yourself (or your loved one) to have a limiting disability?
Yes...........  No............

If yes, do you consider the disability is as a result of acquiring an infection in hospital?
Yes............ No.............

I would describe my ethnic origin as.………………….......
Phone (Home). …………………………………………....
Business. ………………………………………………......
Mobile. ………………………………………………….....
Email…………………………………………………….....
My Membership Contribution: £ 10.00

My Donation (optional): £ ……………….

Total Amount: £ …………......................

I enclose my cheque/crossed postal order made payable to MRSA Action UK
Please do not send cash through the post
SIGNED. …………………………………............… DATE. …………………
PLEASE SEND TO: 

Mrs Mavis Law, Treasurer, MRSA Action UK
9 Beckenham Grove
Winsford
Cheshire
CW7 2YD


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Your Annual Membership entitles you to 10 Newsletters per year, our patient
information leaflets, all the help and support you need and also updates on the
progress so far.