Membership Application Form Fields marked with * are required Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Address* Street Address City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone*Email* Enter Email Confirm Email Date of Birth DD MM YYYY How did you find out about UA?Membership Type*Full MembershipAssociate MembershipCompany MembershipCompany NameChoose your branch*BirminghamCambridgeCotswoldsEast AngliaLeicesterLondon South WestLothian & FifeManchester & NWNewcastle Upon TyneSheffield & DistrictShropshire, Wales and The MarchesSurreyYorkshire & HumbersidePostal BranchType of operation Ileal conduit/urostomy Bladder reconstruction/neo-bladder Continent diversion Other Type of operation (if other selected)Reason for operationHospitalConsultant surgeonAge at date of operationMembership Options*£16 per annumFree for 12 months (new members resident in the UK only)Would you like to add a donation?*YesNoDonation (£) Total £ 0.00 My application for membership of the Urostomy Association is made subject to the Memorandum and Articles of Association of the Urostomy Association (Company Registration No. 06918246) ('The Company'), to any rules for the time being made thereunder, and to any terms for membership applicable to the Company, and in the event of the Company being wound up while I am a member, or within one year afterwards, I undertake to contribute such amount as may be required, not exceeding the guaranteed sum of £1 for payment of the debts and liabilities of the Company contracted before ceasing to be a member, and of the costs, charges and expenses of winding up, and for the adjustment of the rights and contributories among themselves.Declaration* I agree that the annual accounts and Directors' report and Auditor's/Examiner's report on those accounts may be sent by electronic communication to the above email address (if any), published on the website of the Company at www.urostomyassociation.org.uk throughout the period of at least 14 days clear of the date of the meeting and notice of it instead of delivery or sending them by any other means. Your privacy is important to us, and we want to communicate with you in the ways that suit you best, have your consent, and which are in line with UK law regarding data protection. As a result of a change to UK law, we need your consent regarding how we contact you, and for which purposes.Please tick any of the boxes below to give your consent regarding how we contact you:I consent to the Urostomy Association contacting me by: Email Text Phone Post You can withdraw or change your consent at any time by contacting National Office at the Urostomy Association or by email: *protected email* Please note that all processing of your personal data will cease once you have withdrawn consent, other than where this is required by law, but this will not affect any personal data that has already been processed prior to this point.Please tick one or more of the boxes below to give your consent regarding how we use your personal data, or leave them blank if you do not wish to be contacted by us: To keep you informed about the Urostomy Association’s news, events, and activities (you can unsubscribe at any time) To send details of third party events (such as open days), products or services relevant to your urinary diversion. Please note: Any such information is sent from us, and your details will NOT be given to any third party. To pass your contact details to our mailing house for the purposes of sending our magazine If you become a member of one of our local Branches, to pass your details to the local Branch Secretary, who is a volunteer, so that they can send you details of local meetings, newsletters etc. You can grant consent to all the purposes; one of the purposes or none of the purposes. Where you do not grant consent, we will not be able to use your personal data (so for example we may not be able to let you know about forthcoming events) except in certain limited situations, such as where required to do so by law or to protect members of the public from serious harm. You can find out more about how we use your data from our Privacy Notice which is available on our website or from the Urostomy Association.Please note: For social media, your data privacy agreement is with the relevant companies and not the Urostomy Association. However, please be assured that we use these media strictly in accordance with their terms and conditions, and we will never use or share any information about you that we may receive through your use of them.By completing this form, you are confirming that you are consenting to the Urostomy Association holding and processing your personal data strictly in accordance with our Data Privacy Notice. Copies of this can be found on our website: urostomyassociation.org.uk and from the Urostomy Association on request.Gift Aid declarationIf you are a UK taxpayer, we can reclaim tax on your subscription and any donations that you make. This is a valuable source of income to the Association as long as you continue to pay an amount of tax equal to the tax we reclaim on your donations and subscriptions. Please tick the box below which will enable us to do so. I wish the Urostomy Association to reclaim tax on this and any future subscriptions and donations until advised otherwise. Payment Method*Credit/Debit CardPayPalCredit/Debit Card Details* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.