Membership Form
Liverpool Disabled Supporters Association
If you wish to join the LDSA please complete the form below and return to:
LDSA, 10th Floor Chapel Street, Liverpool, L3 9AG
Please enclose a cheque for £5 payable to “Liverpool Disabled Supporters
Association” or “LDSA”. Thank you.
Name…………………….………………………(PLEASE USE BLOCK CAPITALS)
Address ………...…………….….….…………….……………………….....…………
.…………………………...……..…….……………………………………………..……
Post Code ……… ……………...………… Tel no. ….…………………….…...…
Email address ……………………..………….……. ………………….(if applicable)
Preferred method of contact
Do you require mail in an
alternative format?
Post
Email
Yes
No
If yes please state: ………………………………………………………………………..
Please complete the following section. It is entirely optional, but will help us to
understand our membership.
Do you have a disability?
YES
NO
If YES, please indicate your disability:
Wheelchair User
Ambulatory
Visually Impaired
Hearing Impaired
Learning Disability
Other, please specify
DataProtection: The personal data that you provide will be held by the LDSA
Committee and LFC, for the purpose of contacting you in relation to LDSA
activities. Your details will not be passed on to a third party without your
permission.
OFFICE USE ONLY:
Membership Number:
Payment Method:
Membership Expiry Date: