Brainwaves NI Membership Form

BRAINWAVES NI

Membership Application Form
Carer or Patient*
Please enter your own details below, then continue through the form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

PostcodeCountry
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: 000 0000 0000.
Date of birth*

DayMonthYear
Details on brain tumour type and date diagnosed*
Please include as much information as you feel comfortable
What is your relationship to the patient, or your connection to Brainwaves NI (Please note details of relationship, patient history and tumour type)*
Please include as much information as you feel comfortable
On behalf of the patient, please indicate their date of birth*

DayMonthYear
Where did you hear about Brainwaves NI?*
Brainwaves NI members will be invited to outings and events. In these events, you may choose to bring along family member(s), such as children, partners or parents. In order for us to plan for this, we would ask you to provide the names and DOB's of these individuals, please note these below: *
I consent to Brainwaves NI using my photograph(s) and/or video footage for publicity and promotional purposes, including on social media, the website, printed materials, and other communications.*
Information and consent received from individuals is a legal requirement under GDPR regulations. Consent can be withdrawn at any time. Once received, consent and information will be stored in a locked filing cabinet within a secured office and on a password secured computer system for the required timescale I.e. the duration of the membership with BrainwavesNI or the subsequently required timeframe for data retention involving consent. *
DateTime*
Signature*

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**All information is confidential and will not be shared with any other parties**
Registered Charity No:- NIC 103464
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BRAINWAVES NI