What care and support is available for those with deletion 22q11 syndrome?

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Please note that this form is for the registration of new members only.

If you have previously contacted Max Appeal, you may already be registered. If this is the case, please contact us - we would love to know how you're getting on!

Please complete this form:

* = Required

1. Do you have 22q11.2 / DiGeorge Syndrome / VCSF?

Yes
No

2. Please tick AT LEAST ONE of the following statements which apply to you.

I am the parent/carer of a child affected by DiGeorge Syndrome/VCFS/22q11.2 deletion.
I am a Medical Professional/Education/Other Service Provider.
I want to volunteer to help Max Appeal.
I am interested in donating to Max Appeal.
None of the above - I am just interested in finding out more about Max Appeal.

3. Your Details.

Salutation

First Name*

Last Name*

Gender*

Male
Female

Date Of Birth

*Required if you are personally affected by DiGeorge Syndrome/VCFS/22q11.2 deletion.

4. Your Contact Details

Note: If you have ticked "Medical Professional/Education/Other Service Provider" above, the contact details you enter below can be for your place of work. Employer name is specified on the next screen.

Email Address*

We send out regular news and updates to our members via email,
may we send these to this email address?
Yes
No

Telephone

Mobile Phone

Fax

Street Address*

Please note, we need your full address to be able to process your membership.

Town/City*

County/Region*

Postcode*

Country

UK Area

Declaration of Consent under the Data Protection Act 1998
Please note that the details which you have provided on this form will be held on a computer and may also be held in a manual filing system. This data will be processed by Max Appeal and may be included in Max Appeal's annual report. Where you are a correspondent or an officer of Max Appeal, it may also be published on the web pages or in newsletters of Max Appeal. Max Appeal holds events where photographs may be taken, these may be published on web pages or in newsletters of Max Appeal. If you wish to obtain a copy of the data processed, a description of the purposes for which it is being processed, description of any potential recipients of the data, or any information as to the source of the data, please contact Julie Wootton, 15 Meriden Avenue, Stourbridge, West Midlands, DY8 4QN. Please note that Max Appeal is entitled to charge a statutory fee for the provision of this information.