Membership Form Salutation--None--Mr. Ms. Mrs. Dr. Prof. Mx. First Name Last Name Email**Must be a valid email in the format example@example.xxx 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 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 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 First Name: Emergency Contact Last Name: Emergency Contact Phone: Emergency Contact Email:*Must be a valid email in the format example@example.xxx Emergency Contact Street: Emergency Contact City: Emergency Contact EirCode: Emergency Contact Country:--None--Ireland United Kingdom Emergency Contact County:--None--Clare Cavan Cork Carlow Dublin Donegal Galway Kildare Kilkenny Kerry Longford Louth Limerick Leitrim Laois Meath Monaghan Mayo Ofally Roscommon Sligo Tipperary Waterford Westmeath Wicklow Wexford England Wales Scotland 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
