AFAL Asociación Nacional del Alzheimer

Please fill in the following form and send it to us:

(*) Compulsory fields

*Mr/Miss/Mrs

* I wish to join the Association of Relatives of Alzheimer's Sufferers of Madrid, (AFAL) as a:

Sufferer's Relative (Minimum amount: 50,00 €)
Collaborator (Minimum amount: 50,00 €)
Friend Company (Minimum amount: 500,00 €)

*With an amount of € annually.

Bank Details:

*Titular de la cuenta

*Banco / Caja

Address

Locality

*Entidad

*Sucursal

*D.C.

*Nº Cuenta

Please fill in the following information:

*Name of the associate member

* N.I.F

Address

Locality

Province

Postal code

*Telephone number

e-mail

Fax

How did you find us?

If you are joining as a Relative member, please provide the following information:

Sufferer's Details

Name

Relationship

Address

Locality

Province

Postal code

Municipal Council

Telephone number

Date of Birth: (dd-mm-yy)

At what age did symptoms begin?

Relationship

Initial
Moderate
Serious

Are there any other Alzheimer's sufferers in the family?

Do you benefit from any public forms of support? (please specify)

*Would you like to receive information on latest developments?

Yes
No

In accordance to the Organic Law 15/1999 of December 13 regarding the Protection of Personal Details (from now referred to as OLPPD), and the Royal Decree 994/1999 of July 11 on Regulations on Security Measures of Automated Registries that contain Personal Details, the provider of such details is informed and explicitly gives his/her consent to the incorporation of his/her details in the personal registries for which the National Alzheimer’s Association (AFALcontigo) is responsible. AFAL will only use these details with the objective of offering you an up to date and efficient service with the maximum confidentiality and within the limitations provided by the OLPPD and other applicable regulations. The present consent is given while abstaining from prejudice to all the rights that exist by virtue of the previously mentioned normative, especially the possibility to exercise gratuitously the rights of access to the information that you have provided us with and those of rectification, cancellation or objection whenever you please. In order to do so you must write to the National Alzheimer's Association, AFALcontigo (Reference: Personal Details), Calle General Díaz Porlier, Nº 36 Local, 28001, Madrid or by email to: afal@afal.es

*I have read the clause and accept conditions on display

AFAL. ASOCIACIÓN NACIONAL DEL ALZHEIMER