Membership Application to Diabetes Sa
Registration for statistical purposes only
Initials:
Name:
Surname:
Home Contact Number:
Work contact Number:
Cell Number:
Occupation:
I.D. Number:
Address:
City:
Province:
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
North West
Northern cape
Western cape
Postal Code:
Age:
Email Address:
Race:
African
Coloured
Indian
White
Diabetes Type:
Type 1
Type 2
Non-Diabetic
Number of Years as a Diabetic:
Method of Control:
Diet Only
Oral Medication
Insulin
Single annual Membership:
(Includes 4 copies of Diabetes Focus)
R100
Network annual Membership:
(Includes 4 copies of Diabetes Focus)
R250
Donation Amount: