Individual Membership Application Form

Do you identify yourself as a disabled person? (required)
YesNo

Title (required)
MrMrsMissMsDrOther

Your First Name (required)

Your Last Name (required)

Address Line 1 (required)

Address Line 2 (required)

Address Line 3

Town (required)

County (required)

Post Code (required)

Tel. Number (required)

Voice / Minicom

Your Email

Website

Information Preference
EmailPaperBrailleLarge PrintCDAudio

Large print font size

Where did you hear about Disability Wales?
Social MediaFamily/friendSearch engineEventOther (please specify)

Do you consent to Disability Wales Anabledd Cymru holding your information on record? Your personal information will not be shared with a third party for any purpose unless your consent is provided first
YesNo

We will use the information above to send you information about our services such as news and events. Is this OK?
YesNo

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