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Membership

Membership costs £17 per year (£22 for Overseas Membership). If you would like to join, simply fill in the form below, you will then be taken to our secure online payment system.

Membership form
Members must be over 18. If your child has the allergy, please join on his or her behalf. A second adult in the family (e.g. spouse) can be named in the section "2nd member's details."

1st Member's details (must be over 18)
Name
Occupation Home Telephone
Business Telephone Mobile
email address
Address for correspondence
Town
County Postcode
If you don't require a 2nd members details click here
2nd Member's details (must be over 18)
Name
Occupation Home Telephone
Business Telephone Mobile
email address
Details of first individual with allergy
Name
Male Female Date of birth
Allery details for first individual (Tick which apply)
Peanuts Egg Milk Latex
Nuts Do you know which type of nuts? If so, please specify:
Sesame Other seeds Please specify which seeds:
Fish Do you know which type of fish? If so, please specify:
Shellfish Do you know which type of shellfish? If so, please specify:
Fruit Do you know which type of fruit? If so, please specify:
Drugs Do you know which type of drugs eg: pain reliever, antibiotic, anaesthetic, vaccine etc? If so, please specify:
Insect venom Do you know which type of venom? If so, please specify:
Bee Wasp Other  
Other severe allergies - please specify:
Does the allergic person suffer from any of the following:
Asthma Hay Fever Eczema  
Ethnic origin of allergic person eg: Caucasian, Asian etc
If you don't require any other individuals click here
Details of second individual with allergy
Name
Male Female Date of birth
Allery details for first individual (Tick which apply)
Peanuts Egg Milk Latex
Nuts Do you know which type of nuts? If so, please specify:
Sesame Other seeds Please specify which seeds:
Fish Do you know which type of fish? If so, please specify:
Shellfish Do you know which type of shellfish? If so, please specify:
Fruit Do you know which type of fruit? If so, please specify:
Drugs Do you know which type of drugs eg: pain reliever, antibiotic, anaesthetic, vaccine etc? If so, please specify:
Insect venom Do you know which type of venom? If so, please specify:
Bee Wasp Other  
Other severe allergies - please specify:
Does the allergic person suffer from any of the following:
Asthma Hay Fever Eczema  
Ethnic origin of allergic person eg: Caucasian, Asian etc
If you don't require any other individuals click here
Details of third individual with allergy
Name
Male Female Date of birth
Allery details for first individual (Tick which apply)
Peanuts Egg Milk Latex
Nuts Do you know which type of nuts? If so, please specify:
Sesame Other seeds Please specify which seeds:
Fish Do you know which type of fish? If so, please specify:
Shellfish Do you know which type of shellfish? If so, please specify:
Fruit Do you know which type of fruit? If so, please specify:
Drugs Do you know which type of drugs eg: pain reliever, antibiotic, anaesthetic, vaccine etc? If so, please specify:
Insect venom Do you know which type of venom? If so, please specify:
Bee Wasp Other  
Other severe allergies - please specify:
Does the allergic person suffer from any of the following:
Asthma Hay Fever Eczema  
Ethnic origin of allergic person eg: Caucasian, Asian etc
GIFT AID: Make your membership subscription and any donations worth 28% more to the Anaphylaxis Campaign. Simply tick and date the Gift Aid declaration below. If you receive taxable income from UK wages, savings or pensions, we can reclaim the tax.
Yes, I would like the Anaphylaxis Campaign to treat all donations and membership subscriptions as Gift Aid donations.
Date:
NB You must pay an amount of income tax or capital gains tax at least equal to the tax we reclaim on your donations, currently 28p for every £1 you give.
1998 Data protection Act
Your details will be held electronically and will be used only in connection with your membership of the Campaign. We may pass your details to your local regional Campaign co-ordinator, but we will not release data to third parties without permission.
Help? Would you be able to offer help with any of the following:
Local Activities
Media (on occasion we are approached by the media requesting interviews from people affected by severe allergies. Would you be happy for us to approach you about doing an interview?)
Shopping: Which supermarket chain do you use most frequently?
 

Should you have any specific queries, we will do our best to answer them. Please call our telephone helpline on 01252 542029. However, you must always be guided by your GP or consultant.

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