Membership Form Type Of Member:--None--I am living with a diagnosis of COPD I am a family member of a person living with COPD I am a Healthcare professional working in COPD I do not have a diagnosis of COPD Salutation--None--Mr. Ms. Mrs. Dr. Prof. Mx. First Name Last Name Gender Email Phone Street City EirCode Country--None--Ireland United Kingdom State/Province--None--Carlow Cavan Clare Cork Donegal Dublin England Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Longford Louth Mayo Meath Monaghan Offaly Roscommon Scotland Sligo Tipperary Wales Waterford Westmeath Wexford Wicklow Reason for joining: Membership Benefits:I wish to join a local COPD Support Group I wish to join an online COPD Support Group I do not wish to join a support group at this time I wish to be included on the COPD Support Ireland mailing list Preferred Contact Method:E-mail Phone Text/WhatsApp Post By ticking this box I am agreeing to become a member of COPD Support Ireland and to COPD Support Ireland holding my personal data on file during my period of membership for administrative purposes.: Date of Form (DD/MM/YYYY): Emergency contact details only required for member with a diagnosis of copd Emergency Contact First Name: Emergency Contact Last Name: Emergency Contact Phone: Relationship to member:--None--Aunt Child Cousin Daughter Family Father Grandchild Granddaughter Grandfather Grandmother Grandparent Grandson Husband Mother Nephew Niece Parent Partner Sibling's Child Son Spouse Surviving spouse Uncle Widow Widower Wife Other
