The Living Tree - Living well with and beyond cancer - Registered Charity Number 1188213

How to apply to become a Registered Living Tree Member
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Please complete and return the form below.
You can return your completed form to us by saving then completing this form on your computer, then
either 1) emailing it as an attachment to thelivingtreedorset@gmail.com,
    or 2) print it and post it back to us at this address:
          Mrs J Millar, Chair, The Living Tree, c/o The Old Vicarage, Bradpole, Bridport, Dorset. DT6 3JA

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Application to become a Charity Member
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> I apply to become a Living Tree Registered Member.

> I support the aims and objectives of The Living Tree Cancer Support Charity and agree to act in the best interests
of the Charity.

> If I am accepted for membership, I accept that my personal data
  will be held on a secure database and will not be passed to any third party without my express permission,
  and the data will be retained according to Charity Commission regulations.

Please type each of your responses after the > or on the line following the name of the requested information below.
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Name>

Likes to be known as>

Email address>

Home phone>

Mobile phone>

Address>

Postcode:

Emergency Contact Name>

Emergency Contact Phone>

Publicity Preference Permission
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In order for The Living Tree to comply with data protection and confidentiality regulations, we are required
to obtain your written consent to use photographs, video or quotes that may feature you in our publications.

We may like to use your photograph, film and words to publicise events in newspaper articles, magazines
and other media such as posters, websites, social media, information leaflets, brochures and newsletters.

I hereby do*/do not* (*delete as appropriate) give permission for my personal information to be used,
or myself to be identified in publicity work on behalf of The Living Tree.
(You may withdraw your consent at any time.)
  
Please type your signature>

Date you completed this form>