Registration Form Membership typeMembership type *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)Notes on Membership Notes on Membership 1. Ordinary and Life Membership is open to persons with epilepsy. 2. Ordinary and Life Membership is open to all other persons who are interested in the cause of epilepsy and willing to subscribe to the objects of Epilepsy Care Group (Singapore). 3. Only active Ordinary and Life members who are above 18 years of age and who have been members of the Group for at least 12 months shall have the right to hold office in the Group. 4. Corporate Membership is open to all firms, companies, organisations and institutions in Singapore who subscribe to the objects of the Epilepsy Care Group (Singapore). Only two representatives are allowed for each corporate member. Such members have no voting rights and cannot hold office. 5. Any member may resign his membership by giving notice in writing to the effect and paying all monies due. 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. My ParticularsI am *A Person with EpilepsyA Caregiver/ParentA VolunteerOthersIf you selected "Others", please specify Name of applicant (as in NRIC/Passport)Title *DrMrMrsMdmMissName *Gender MaleFemaleAddress *Mailing address : if different from aboveTelephone (H) *Please indicate handphone number if you do not have house phoneHandphone Telephone (O) Email *Date of Birth enter in dd/mm/yy formatOccupation Nationality * Medical Information (Strictly private and confidential)Name of patient *NRIC No./DoB *Weight Height The important things about my epilepsy : My epilepsy was first diagnosed on My type of seizure/epilepsy is called *I have seizures at least (state frequency)I take tablets for my epilepsy. The tablets I take are called The people I can talk to about my epilepsy/seizures are : My doctor : Hospital/Clinic : My parents : My 'carer' : Important! *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 receive an email where you can print the details of your submission to be attached to your payment for subscription and posted to the following address : MEMBERSHIP APPLICATION EPILEPSY CARE GROUP (SINGAPORE) Epilepsy Support Development Centre 3779 Jalan Bukit Merah #02-03 Bukit Merah Community Hub Singapore 159462 VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
