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Membership Form - Child, Young Person under 16

Your Child's Contact Details

Additional Details About Your Child

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Parent/Guardian Details

At least one Parent/Guardian must be submitted for children under 16 years.

  • Parent/Guardian One

  • Parent/Guardian Two

Your Child's Medical Details

  • Medical Condition(s)

    Please tick all that apply

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  • Any Other Conditions, eg. epilepsy, cerebral palsy, etc.
  • Shine produces ‘SHUNT ALERT’ cards which people with hydrocephalus can carry. The card tells others that you have a shunt, and what to do in an emergency.

Your Child's Mobility

Your Child's Health

Your Child's GP's details

Your Child's Education

Membership Details

Local Health

  • Would you like to receive our free triannual membership magazine Together (please tick one)?

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  • Shine has a club for members ages 0-11 called Benny and Bella Bear Club.
    Please select which bear you would like to receive.

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