MEMBERSHIP APPLICATION ( POSTAL ) FORM

MEMBERSHIP FEE IS £12.00 PER YEAR.
PLEASE COMPLETE THE FORM IN BLOCK CAPITALS

MR/MRS, ETC:   .....................................   FORENAME/GIVEN NAME:   ..........................................……

SURNAME:  ..................................................................................................   D.O.B.:  .........................

ADDRESS:  ...........................................................................................................................................

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POST CODE:  ....................................................   TELEPHONE NO;  ....................................................

SIGNATURE:  ........................................................................          DATE:  .........................................

 

TYPE OF DISORDER, PLEASE CIRCLE AS APPROPRIATE ( UP TO A MAXIMUM OF 5 )

 

01	agoraphobia		14	driving		27	moths		40	thunder / lightning
02	bees & wasps		15	eating		28	mice		41	tranx withdrawal
03	birds		16	feeling unreal		29	noise		42	vomit
04	blood		17	flying		30	O.C.D. ( thoughts )		43	wind / weather
05	blushing		18	frogs		31	panic		44	carer ( O.C.D. )
06	body defects		19	general anxiety		32	relaxation		45	carer ( panic )
07	cats		20	heights		33	schools		46	carer ( phobia )
08	children fears		21	hospitals		34	sexual		47	anxiety in children
09	claustrophobia		22	hyperventilation		35	snakes		48	O.C.D. (hoarding)
10	daddy long legs		23	illness & death		36	social		49	O.C.D.(contamination)
11	darkness		24	injections		37	space		50	O.C.D. ( checking )
12	dentists		25	insects		38	sphincteric		51	O.C.D. ( counting )
13	dogs		26	monophobia		39	spiders		52	O.C.D. (symmetry )

Please tick this box if you want a TELEPHONE SUPPORT SERVICES Application Form: [     ]

  Please return this form  the Information Booklet Form, The Membership Fee and a Large (9 x 6) Stamped Self Addressed Envelope to:

The Membership Secretary, No Panic, 93 Brands Farm Way, Telford, Shropshire, England, TF3 2JQ.

 Cheques/Postal Orders should be made payable to No Panic.

For those people wishing to join or renew their membership please note:
Telephone orders using credit or debit cards are welcome - simply telephone 
the No Panic Office on 01952 590005. Between  9am - 5pm, Mon - Friday.

Postage stamps to help cover costs would be gratefully received