Membership Form

Payment reference - Please give the order number (see order details or confirmation email of website membership purchase) or Surname on cheque / bank account (required)

Title (required)

First name (required)

Surname (required)

Address (required)

Town (required)

County/Country (required)

Postcode (required)

Phone Number

Email (required)

Date of birth (required, under 16 membership is free if submitted with an adult membership)

If below 16, name of responsible adult, please put n/a if not applicable (required)

Responsible adult contact details, please put n/a if not applicable (required)

Do you consider yourself to have a disability? please select the correct option
YesNo

Do you use a wheelchair? please select the correct option
YesNo

If yes to either of the questions above please give brief details, including any mobility aids used.

LFC Season Ticket or Membership type please select the correct option
NoneSeason TicketMembership

Membership required please select the correct option (associate = family member or carer/pa of disabled person)
AssociateDisabled

Previous membership please select the correct option
New MemberRenew existing membership

If renewing membership please state your previous membership number, it starts LDSA10 and can be found on your most recent card

Preferred method of contact please select the correct option
PostEmail

Method of payment please select the correct option
WebsiteBank Transfer

I grant permission for the LDSA to retain and use my data as per their GDPR Policy Read Policy

I have read and agree to the rules set out in the LDSA constitution Read Constitution

The send button below will only become active once all questions are fully completed, please ensure you have chosen the correct options.

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