Coeliac UK – Isle of Man Voluntary Support Group
Isle of Man Registered Charity Number 961
Local Membership application
I hereby apply for local membership of the Group in Isle of Man. I understand that this does not confer membership of Coeliac UK or supply of the Food & Drink Directory etc.
(full Membership of Coeliac UK is available from www.coeliac.org.uk and includes membership of the nominated local Voluntary Support Group)
I understand that I will receive notification of group events in the Isle of Man, either by email or by post. Local membership covers the costs of these notifications. The current rate is £5 per year, commencing and ending with the AGM in April of each year.
Name (as you wish on the notification)House Number or Name
Street
Town
Postcode
Email (preferred to reduce cost)
(Telephone number if wished)
o I / my child have been medically diagnosed with Coeliac disease or Dermatitis Herpetiformis after either a small bowel biopsy, or antibody test.
o I support a relative or friend who has been medically diagnosed – please state age if a child......
o I follow a Gluten Free diet for other reasons......
o I have a professional interest (e.g. doctor, dietician, caterer, food retailer) in a Gluten Free diet – please state the interest......
(The answers to these questions help us in our quest to find the estimated 1 in 100, or 800 odd people affected in IOM, and provide suitable support and events for them.)
I understand that my personal details will be held and processed by the Group as data under the Data Protection Act 2002 (registered user #N7473)
o I enclose a cheque for £5 made payable to “Coeliac UK – IOM Voluntary Support Group”
o I have passed this form to the Treasurer at the AGM or other meeting with £5 cash.
Signed ...... Date......
Coeliac UK IOM Voluntary Support Group – Manx Charity #961 –
Secretary – Mr K H Barber, 6 Pinehurst Close, Douglas, IM2 1PL
Phone 620224 e-mail: