important note : all fields marked with a red asterisk (*) are required to be filled in.
I / We hereby apply for *
Ordinary Membership (S$20 pa) Renewal of Membership (S$20 pa) Corporate Membership (S$500 pa) Life Membership (S$100) Conversion to Life Membership (S$100)
click here for Notes on Membership. By submitting this form, you are assumed to have read and understood the membership conditions.
of the Epilepsy Care Group (Singapore) [ECGS] and understand that ECGS reserves the right to decline an application without giving any reason and is not obligated to respond to any request form from an unsuccessful application.
Name of applicant (as in NRIC/Passport)
Title* Dr Mr Mrs Mdm Miss
Pager
Medical Information (Strictly private and confidential)
The important things about my epilepsy :
1. My epilepsy was first diagnosed on dd mm yy
2. My type of seizure/epilepsy is called *
3. I have seizures at least (state frequency)
4. I take tablets for my epilepsy. The tablets I take are called
5. The people I can talk to about my epilepsy/seizures are :
By submitting the form, you are deemed to have read and understood the membership requirements and objectives and that all information you have submitted is truthful and best to your knowledge.
Click on the submit button below. You will be directed to a page where you can print the details of your submission to be attached to your payment for subscription and posted to the following address :
