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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
patient status. Please update our RELATIVE OF PATIENT
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 ‘SUPPORT’ MAGAZINE UNLESS THERE IS
ALREADY ANOTHER ASSOCIATION MEMBER AT YOUR ADDRESS RECEIVING IT?

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.