EmailMe Form - Heart Kids NZ Membership Form

Part A - Heart Child / Teen / Adult / Prenatal Details

Are you a heart child, heart teenager, heart adult or a parent expecting a heart child? *

If you are expecting a heart child, please select Prenatal.

Title:

First Name: *

Middle Name:

Last Name: *

Preferred Name:

Date of Birth: *

DD / MM / YYYY

Ethnicity: *

Providing this information will assist with family matching. Demographic information is also very helpful in assisting with research projects and funding opportunities.

European:

Pacific Island:

Asian:

Address: *

Suburb: *

Type the first letter of your town/city and the list will drop down to the towns/cities beginning with the same letter.

Town/City: *

Type the first letter of your town/city and the list will drop down to the towns/cities beginning with the same letter.

Postcode: *

Click Here for the Address and Postcode Finder

Mobile Number: *

Email: *

Congenital Heart Condition (Primary Diagnosis): *

Only one condition can be selected. If there are two or more conditions, please select Multiple Heart Defects.

Congenital Heart Condition (Secondary Diagnosis):

Acquired Heart Condition (Primary Diagnosis): *

Procedure: *

Only one procedure can be selected. If there have been two or more procedures, please select Multiple Procedures.

Other Associated Conditions: *

Only one condition can be selected. If there are two or more conditions, please select Multiple Conditions.

What else would you like us to know? *

Part B - Parent / Primary Caregiver and/or Next of Kin

The Parent/Primary Caregiver will receive all information, including post, for heart children and teens under 18 years.

Title: *

First Name: *

Last Name: *

Preferred Name:

Date of Birth:

DD / MM / YYYY

This information helps us secure funding opportunities.

Ethnicity: *

Providing this information will assist with family matching. Demographic information is also very helpful in assisting with research projects and funding opportunities.

European:

Pacific Island:

Asian:

Relationship to Heart Child/Teen/Adult: *

Address details the same as Part A? *

Yes

No

Address: *

Suburb: