Website reg form

SBHI Registration Form

SBHI offer services and supports to anyone in Ireland living with Spina Bifida and/or Hydrocephalus. Membership is optional and does not affect your ability to avail of these services and supports. Membership runs from January-December and is free for under 18s / €5 per year per adult. Only paid members have the ability to vote at our annual AGM.
About you

If you are a parent of someone with the condition(s) please fill in your child's information below:
Title*
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender
Connection to SBHI*
Contact Information
Address*

Street Address

Street Address Line 2

CityCounty

Eircode
Email*

Confirmation Email
Mobile Number*
Please enter a valid phone number.
Emergency Contact

Please provide the details of who we can contact in case of emergency
Relationship to you*
Emergency Contact Name*

First NameLast Name
Emergency Contact Mobile Number*
Please enter a valid phone number.
Medical Information
Medical Conditions - Please select all that apply*

Spina bifidaHydrocephalusOther ( Please provide further information below )None
Further information
Do you have a shunt for Hydrocephalus management?*

YesNoNot Applicable
Consents
SBHI has a team of Family Liaison Officers, would you like your details to be passed on to the Family Support Worker when completing this form?*

YesNo
SBHI has volunteer Branches covering some counties of Ireland. Are you happy for your details to be passed on to the local Branch if there is one in your area?*
Method of contact/ Contact Consent

I consent to contact via all methods ( email, phone call, post )Contact me via POST onlyDo not contact me
Photo consent: SBHI host many events throughout the year for our members, some of which you or your family may attend. During these events we may take photographs, video recording or audio recording/quoted remarks which include members, their families, volunteers and staff. From time to time, these forms of media are used by SBHI for printed publications or materials, electronic publications of presentations, the SBHi website or the SBHI Facebook pages. In order for us to do this, we are obliged to ask you to select your preferences
Do you give permission to SBHI to use photos/recordings which may include you, and/or your child and/or your family at various events within the Association throughout the year for promotional material or public information*

YesNo
Do you want to sign up to our monthly SBHI Newsletter for information on upcoming events, meetings and the latest SBHI news?*

YesNo
Membership is optional and does not affect your ability to avail of SBHI services and supports. Membership runs from January-December and is free for under 18s / €5 per year per adult. Please note that only paid members have the right to vote at our annual AGM. Would you like to become a member?

YesNo
Once submitted, your local Family Liaison Officer will be in touch in the coming days to advise further on the supports and services available to you.
Should be Empty:

SBHI Registration Form

About you

Contact Information

Emergency Contact

Medical Information

Consents

Once submitted, your local Family Liaison Officer will be in touch in the coming days to advise further on the supports and services available to you.