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

Shine would like to keep you up to date with our work including fundraising and volunteering and what you are helping us to achieve. We will keep your details safe and you can always change your preferences at any time just by contacting us. Please read our privacy policy for more information about how we look after your details.

Yes, I'd like to hear from you by email

Yes, I'd like to hear from you by post

Yes, I'd like to hear from you by telephone

Yes, I'd like to hear from you by text message

How did you hear about Shine?

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