EdgCARE Membership Application Form

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Thank you for applying for "Membership" status within the EdgCARE service. The person completing this form is considered the "Primary Member" and will be responsible for informing us of any updates to your details (address etc) and also payment.

1. Please enter your Full Name including any middle names: *

First Name	*
Middle Name
Surname	*

2. Please indicate your gender: *

Male
Female

3. Please enter your full Postal Address: *

First Line of Address	*
Second Line of Address
Town/City	*
Postcode	*

4. Please enter your Date of Birth: *

	DD/MM/YYYY
DOB:

5. Please enter your Contact Details: *

Telephone (Landline)
Mobile	*

6. Please enter your Email Address: *

7. Please enter below the details of any other people residing at the above address who will be included in your Family Membership scheme

	Name	DOB	Gender	Contact Number	Email Address
Family Member 1	Family Member 1 Name	Family Member 1 DOB	Family Member 1 Gender	Family Member 1 Contact Number	Family Member 1 Email Address
Family Member 2	Family Member 2 Name	Family Member 2 DOB	Family Member 2 Gender	Family Member 2 Contact Number	Family Member 2 Email Address
Family Member 3	Family Member 3 Name	Family Member 3 DOB	Family Member 3 Gender	Family Member 3 Contact Number	Family Member 3 Email Address
Family Member 4	Family Member 4 Name	Family Member 4 DOB	Family Member 4 Gender	Family Member 4 Contact Number	Family Member 4 Email Address
Family Member 5	Family Member 5 Name	Family Member 5 DOB	Family Member 5 Gender	Family Member 5 Contact Number	Family Member 5 Email Address
Family Member 6	Family Member 6 Name	Family Member 6 DOB	Family Member 6 Gender	Family Member 6 Contact Number	Family Member 6 Email Address
Family Member 7	Family Member 7 Name	Family Member 7 DOB	Family Member 7 Gender	Family Member 7 Contact Number	Family Member 7 Email Address
Family Member 8	Family Member 8 Name	Family Member 8 DOB	Family Member 8 Gender	Family Member 8 Contact Number	Family Member 8 Email Address
Family Member 9	Family Member 9 Name	Family Member 9 DOB	Family Member 9 Gender	Family Member 9 Contact Number	Family Member 9 Email Address

8. Do you give your Consent for our service to communicate with you by email? *

Yes
No

9. Please tick to indicate which type of email communications you consent to receiving? *

Un-encrypted (non-secure)
Encrypted (secure – you will need to go through an online process to access the email / attachments)

10. Do you give your Consent for our service to communicate with you by SMS? *

Yes
No

11. Please enter details for your Next of Kin:

Name
Relationship
Telephone

12. Are you registered with an NHS GP? *

Yes
No

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