Standard Membership Application

MACS Membership Application
Thank you for your interest in joining MACS (Microphthalmia, Anophthalmia & Coloboma Support). We are a membership organisation in the UK and as a member, you will be able to access a range of services which we hope will be helpful to you, and have voting rights at our Annual General Meeting.

If you would like help completing the form or would like the data in another format please call Sharon on 07395 280764 or email on sharon@macs.org.uk and we will endeavour to help in the way that suits your needs best.

Use this form if you are 18+ and have Microphthalmia, Anophthalmia or Coloboma; or if you are a parent, guardian or carer of someone with one of these conditions. You also need to be based in the United Kingdom; there is a separate form if you are outside the UK and wish to become a Friend of MACS.

MACS uses the information you submit to provide services in line with the MACS constitution. Your data is confidential and will not be sold or misused. Where it needs to be shared with a 3rd party organisation that provide services that you specifically sign up for, we will ask for your consent first. Please see our privacy policy for details of how MACS uses personal information.
Your details

To help us with your membership request, please provide information about yourself as our primary contact.

Please use a unique email so that we can correctly identify you. Please provide at least one phone number.
1. Title
1. First Name*
1. Last Name*
1. Email*
example@example.com
1. Mobile

000000000000000000
1. Home Phone

00000000000000000
1. Address*

Street Address

Street Address Line 2

Town/CityCounty

Post CodeCountry
A few more details...

We collect diversity information about members. The information you provide will remain confidential, but you do not have to provide it if you do not feel comfortable:
1. Your Gender*
1. Self Describe
1. Your Ethnicity
1. Do you have a MACS condition?*

Further information about your conditions
1. Microphthalmia?*
1. Anophthalmia? *
1. Coloboma? *
1. Other Conditions - do you have any other conditions that may be relevant to your membership?
1. Registered sight impairment status ?
1. Your Date of Birth*

DayMonthYear

Additional Member with a MACS Condition
Dependant family member with a MACS condition

Where there is a dependant family member with one or more of the following conditions: Microphthalmia, Anophthalmia and Coloboma, then please provide their details.

For adults and children aged 13 and over, please also confirm they have given you their consent.

We will collect details of other family members when we contact you.
1. Do you wish to add a household member with a MACS Condition?*

About your Dependant
1. Relationship - As carer of a person in your household with a MACS Condition - please describe your relationship to them*
2. Title
2. First Name*
2. Last Name*
2. Have they given permission to be included?*
2. Microphthalmia?*
2. Anophthalmia? *
2. Coloboma? *
2. Other Conditions - do they have any other conditions that may be relevant to your membership?
2. Registered sight impairment status ?
2. Over 18?*
2. Date of Birth*

DayMonthYear
2. Email
example@example.com
Confirmation

We collect diversity information about members. The information you provide will remain confidential, but you do not have to provide it if you do not feel comfortable:
2. Gender*
2. Self Describe
2. Ethnicity

MACS Membership Application

Further information about your conditions

Additional Member with a MACS Condition

About your Dependant

Final Page