Membership Type:
Section 1 - Personal Information
1.1 Title:
1.2 First Name:
Last Name:
1.4 Birth Date:
1.5 Gender:
1.6 Address Line 1:
1.7 Address Line 2:
1.8 City:
1.9 County:
1.10 Postal Code:
1.11 Email:
1.12 Phone Number:
1.13 Member Photo:
For information on the requirements of the member photo please see section 8
1.14 Preferred Communication Method:
1.15 Are you an Armed Forces Veteran?
Section 2 - Medical Information
2.1 Are you on any Medication?
2.2 What side effects, if any, do you have from your medication?
2.3 Medical Conditions:
2.4 Proof of Eligibility:
For information on the requirements of the documents required please see section 8
2.5 Sight Loss:
2.6 Bladder/Bowel Weakness/Illness:
2.7 Hearing Impairment:
2.8 Invisible Disabilities:
2.9 Mobility:
2.10 Non-Verbal:
2.11 Are you at a significant disadvantage without your Assistance Dog?
Section 3 - Assistance Dog Information
3.1 Assistance Dog Name:
3.2 Assistance Dog Date of Birth:
3.3 Assistance Dog Breed:
3.4 Assistance Dog Colour:
3.5 Assistance Dog Distinguishing Features:
3.6 Assistance Dog Photo:
For information on the requirements of the Assistance Dog photo please see section 8
3.7 Has your Assistance Dog ever been reactive towards humans or other dogs?
3.8 Is your Assistance Dog Reliable?
3.9 Microchip Number:
3.10 Microchip Database Provider:
3.11 Type of Assistance:
Section 4 - Next of Kin Information
4.1 Next of Kin First Name:
4.2 Next of Kin Last Name:
4.3 Next of Kin Relationship to member:
4.4 Next of Kin Email:
4.5 Next of Kin Telephone Number:
Section 5 - Agreements
5.1 Agreement 1:
5.2 Agreement 2:
Section 6 - Consent
6.1 Consent for Contact:
Section 7 - Completing This Form
This section is only required if someone else has completed this form for you
7.1 Full Name:
7.2 Relationship to Member:
7.3 Contact Telephone Number:
7.4 Contact Email:
Section 8 - Form Information
8.1 File Upload Information
Member Photo should be a passport style photograph, however you are able to smile. This should be forward facing, wearing glasses (if you normally wear glasses), no hats, and on a plain background.
Assistance Dog Photo should be the dog in a forward facing seated position and should show the shoulders and head of the dog.
Proof of Eligibility should be a copy of your PIP award letter, a copy of your blue badge, or a letter form your Dr stating that you have a long term health condition that has lasted longer than 12 months, and impacts your daily living.
8.2 Code of Conduct
Our membership code of conduct is available in the resources section of our website.