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Application form

Membership of Meningitis Research Foundation is free, and is open to those families, or individuals, who have experience of meningitis or septicaemia.

Fields marked * are mandatory

Your name: *

Your address: *

Country: *

Telephone (daytime):

Telephone (evenings):

E-mail address: *

Please tell us who you know who has suffered from meningitis or septicaemia.

The name of the person who had meningitis or septicaemia:

Relationship to you:

Other:
(please specify)

Type of meningitis or septicaemia suffered from:
Date suffered:
(day/month/year)

Age at which the person who had meningitis or septicaemia contracted the disease(s):

Outcome:

On receipt of your request for membership further information will be sent.

Data Protection Statement:
Any information you provide will/may be held by Meningitis Research Foundation. We may use it to inform you about events and services offered by ourselves or by selected third parties. This may be by post, telephone or e-mail. If you prefer not to receive these communications please tick the appropriate box below:

No future contact by 3rd party partners
Please tick this box if you are happy to receive email and other electronic forms of communication from Meningitis Research Foundation.

Click here to order information resources about meningitis and septicaemia and the work of the Foundation.

Alan Farnan

Meningococcal disease

Our larger than life wonderful son is no more.