Membership Form (over 16)

Personal details

Title *

First name *

Last name *

Date of Birth *

Gender

Mobile number

Phone number

Address Line 1 *

Address Line 2

Town / City *

County

Postcode *

Email address *

Ethnic Group *

Main Language spoken *

Living Arrangements

Education

Further Education

Higher Education

Specialist residential college

Health information

Disabilities (tick as appropriate)

Details

Shunt information

What type of shunt do you have fitted?

Ventriculoperitoneal

Ventriculoatrial

Lumbarperitoneal

Endoscopic third ventriculostomy

I don't know what type of shunt I have fitted

I do not have a shunt fitted

Is your shunt programmable

Yes

No

I don't know

Would you like a shunt alert card? *

Mobility information

Which best describes your current level of mobility

Please describe your current wheelchair use

Occasional use

Electric outdoor

Manual wheelchair

Electric indoor

I do not use a wheelchair

Next of kin

Primary contact

Forename *

Surname *

Relationship

Address 1

Address 2

Town

County

Postcode

Date of Birth

Telephone *

Mobile

Secondary contact

Forname *

Surname *

Relationship

Address 1

Address 2

Town

County

Postcode

Date of Birth

Telephone *

Mobile

Legitimate Interest:

Following the introduction of new data protection laws in May 2018, Shine will communicate with members under the terms of ‘legitimate interest’

‘Legitimate interest’ allows us to use your personal information in ways you could reasonably expect, and which have a minimal impact on your privacy. In each instance, we endeavour to carefully consider any impact on your personal rights and interests.

Shine will communicate with you in line with the benefits of membership as set out within your application. Typical examples of when we might use this approach include:

To tell you about the work Shine is doing
To notify you of news, research and developments relevant to your condition
To invite you to events where you can meet and connect with professionals and peers
To share good news and success stories from the Spina Bifida and Hydrocephalus communities
To seek your views on upcoming plans and projects

Supporters Consent:

In addition to news, updates and invitations, Shine would also like to email you with information about ways you can support the charity and our work in the future. This may include:

Ways to donate or raise money for us
How to get involved with campaigns
Volunteering opportunities

If you consent to receiving emails from us about upcoming appeals and opportunities please tick the box below.

I consent to receive emails from Shine about ways to support the charity

How to change or withdraw your consent:

You can change the way you hear from us or withdraw your permission for us to process your personal details at any time by using our contact form on the ‘Contact Us’ page or by calling us on 01733 555988.

Membership (16 years of age and over)

Fill out the form below

Personal details

Health information

Shunt information

Mobility information

Please describe your current wheelchair use

Next of kin

Primary contact

Secondary contact

Legitimate Interest:

Supporters Consent:

How to change or withdraw your consent: