Member Registration

Complete the form below to register as a new member.

Name and contact information

Name(Required)

First Last

Email(Required)

Mobile telephone(Required)

Landline telephone (Optional)

Account information

Username(Required)

Password(Required)

Enter Password Confirm Password

About you

Date of birth(Required)

DD slash MM slash YYYY

Your address(Required)

Street Address City County Post code

Illness or Conditions

Have you or a family member/friend been diagnosed with an Illness/condition?(Required)

You

Family Member / Friend

Carer(Required)

Were you or are you the primary carer for the family member or friend?

Yes

No

Name of family member or friend(Required)

First Last

Name of Illness/condition?(Required)

Date of diagnosis?(Required)

DD slash MM slash YYYY

Do you or the family member/friend suffer from any other conditions?(Required)

You can use the + sign to add a further condition.

Why You Would Like To Become A Member

Which Services are you interested in?(Required)

Counselling

Therapies

Support

Friendship & a listening ear

Information/Advice

Attend Events & Classes

Attend Group Meetings

Attend Community Meetings

Reason for wanting to become a member?(Required)

Emergency Contact

Name of contact(Required)

Telephone number of contact(Required)

GP/Doctors Details

GP/Doctors name(Required)

GP/Doctors address(Required)

Street Address City County Post code

GP/Doctors telephone(Required)

GP/Doctors email address

How did you here about us?

Please select an option(Required)

Please provide the name of the organisation(Required)

Please provide details of your referral(Required)

Which organisation referred you?

Please provide further details(Required)

Consent(Required)

I confirm that I have read and understood the Privacy Policy and I consent to Sefton Support Group processing my personal data in accordance with its terms. I understand that my information will be used solely for the purposes outlined in the Privacy Policy, and I can withdraw my consent at any time.

I agree to the privacy policy.

Name

This field is for validation purposes and should be left unchanged.

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