Union
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Dutch/Nederlands
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Application for membership

The membership becomes effective after the contribution has been received and gives you at least:







Application form

Fields marked with an asterisk (*) are required fields.
Salutation
Mr.
Mrs.
Family
Surname *
Initials *
Address *
Zipcode *
Residence *
Telephone *
E-mail address *
Profession (1)
How did you find us?
Are you a patient yourself (2)
Inventory
Name patient
Birht date patient (dd-mm-yyyy)
Sex
Location of spots on the body
Date of diagnosis (dd-mm-yyyy)
Name hospital
Name doctor
Abnormalities
Genetic reasearch performed?
Hospital
Name hospital/doctor
Internet
Website address
Yes
Other
Description
No
Interested in annual meeting?
Suggestions/remarks
Yes
No
Yes
No
Male
Female
Country *
(1) Quite often members (or parents of members) have a profession that could support our organisation (and hereby patients). The experience shows that practically everybody is willing to support us somehow.

(2) In case you are patient yourself or parent/fosterer of the patient, please fill in the inventory form as well.
• Four times a year a newsletter with lots of information
• Access to names, addresses and medical data of other patients.
• Annual meeting with other patients and/or parents.
Organisation
Policy
Contact information
Become a donor
Become a sponsor
Medical advisors
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Membership