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Application Form

To apply to become a member of the Angus Cardiac Group please complete the online application form below or download a word version of the application form.  N.B.  ALL boxes must be completed.

1.Details of Applicant - Confidential

Surname
Other Name(s)
DOB
Address
Post Code
Telephone number (incl. area code),
Home telephone number
Work telephone number
Email

2.I wish to become a member of the ANGUS CARDIAC GROUP

Tick whichever of the following apply to you
I have coronary heart diseaseI have had a heart attackI have had heart surgeryI suffer from anginaI am a partner of someone with heart diseaseI am a carer of someone with heart diseaseI have an interest in the aims and activities of the group

3.Doctor’s Details - Confidential (for emergency use only)

Name
Practice Address
Telephone Number

4.Emergency Contact - Confidential (for emergency use only)

Name
Relationship to member
Address
Post Code
Home telephone number
Work telephone number

5.As a member I agree to:

  • Abide by the group’s constitution
  • Support the aims and activities of the group
  • Update the above information as necessary
  • The Angus Cardiac Group storing and using the above information in
    pursuit of the group’s activities.

6.Further Information

I have read an online copy of the group’s constitution
I wear a size Small, Medium, Large, X Large T Shirt
SmallMediumLargeX-Large

Please Note:

I have no objections to photographs being taken at Angus Cardiac Group events for use in the local press or on the website.