Admin Salesforce MEMBERS form

Salutation–None–Mr.Ms.Mrs.Dr.Prof.Mx.

First Name

Last Name

Email

Phone

Street

City

EirCode

Country–None–IrelandUnited Kingdom

State/Province–None–CarlowCavanClareCorkDonegalDublinEnglandGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonScotlandSligoTipperaryWalesWaterfordWestmeathWexfordWicklow

Type Of Member:–None–I am living with a diagnosis of COPDI am a family member of a person living with COPDI am a Healthcare professional working in COPDI do not have a diagnosis of COPD

Reason for joining:

Membership Benefits:I wish to join a local COPD Support GroupI wish to join an online COPD Support GroupI wish to be included on the COPD Support Ireland mailing list

Preferred Contact Method:E-mailPhoneText/WhatsAppPost

Signature:

Date of Form (DD/MM/YYYY):

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Phone:

Emergency Contact Email:

Emergency Contact Street:

Emergency Contact City:

Emergency Contact EirCode:

Emergency Contact Country:–None–IrelandUnited Kingdom

Emergency Contact County:–None–ClareCavanCorkCarlowDublinDonegalGalwayKildareKilkennyKerryLongfordLouthLimerickLeitrimLaoisMeathMonaghanMayoOfallyRoscommonSligoTipperaryWaterfordWestmeathWicklowWexfordEnglandWalesScotland

Relationship to member:–None–AuntChildCousinDaughterFamilyFatherGrandchildGranddaughterGrandfatherGrandmotherGrandparentGrandsonHusbandMotherNephewNieceParentPartnerSibling's ChildSonSpouseSurviving spouseUncleWidowWidowerWifeOther