Membership Form

To join the Association print off this form and send it, with your £10 membership fee, to:

RLS-UK/EKBOM SYNDROME ASSOCIATION, 42 Nursery Road, Rainham, Gillingham, Kent ME8 0BE

Membership No (if known) .......................

Print Name ……………………………………………………………………………………………………...…

Mailing Address ……………………………………………………………………………………………….....

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Telephone Number .................................................................................................

Email address (please print clearly) ……………………………………………………………….……..

Year of Birth ...........................................

Why do we want this? By having a record of our members' years of birth we are able to work out the average age of our members and estimate whether or not our attempts at recruiting patients of ALL ages has been successful. Any information you provide will remain strictly confidential and is not available to ANY THIRD PARTY.

Would you be willing to participate in important research regarding RLS?

Yes..........................................  No.............................................

More information - On occasion RLS-UK?ESA are approached by companies or individuals with a specific interest in RLS and by agreeing to participate we will pass on a contact telephone number for these individuals to contact you and expain their research further. You are under NO OBLIGATION TO CONSENT TO THIS. However, any input is often warmly received by researchers. For an idea of the types of research undertakensee the link on the home page Ellie MacDonald.

Please indicate if you would like to volunteer any elements of help on our committee when a vacancy arises.

Yes Please................................. No Thank You.................................

Please make cheques payable to RLSUK-ESA/Ekbom Syndrome Association