Membership Application Form

DebRA Membership is free of charge and entitles you to:

All DebRA literature
Newsletter - the latest news on healthcare, welfare and research as well as features on people with EB
Annual Review - our achievements over the last financial year and plans for the year ahead
Invitations to local and regional meetings as well as the Annual Conference and AGM
Voting rights at the AGM
Use of the three DebRA holiday homes

If you would like to become a member then please complete and submit the form below.

Alternatively contact Cynthia Richards, DebRA Welfare Co-ordinator, on 01344 771961 or email cynthia.richards@debra.org.uk for more information.

Title *

Surname *

Forename/s *

Address *

Postcode *

Telephone *

Mobile

Date of birth *

Reason for membership *

I have EB

I am a relative/friend of someone with EB

I am a carer of someone with EB

For full family membership please add the names and date of birth of each family member, stating if they have EB

Please state type of EB if known

Dystrophic

simplex

junctional

Please state EB subtype if known

Do you have any other relations with EB?

yes

Please state their relationship to you