CHECT Membership Form
*there is no charge for membership.
Your contact details
Title *
Required
Your first name: *
Your answer
Your Surname: *
Your answer
Partner's title and full name:
Your answer
Full address including postcode: *
Your answer
Your home phone number:
Your answer
Your mobile phone number: *
Your answer
Your email address: *
Your answer
Your partners mobile number:
Your answer
Your partners email address:
Your answer
First language spoken?
Your answer
How we keep in touch
I am happy for The Childhood Eye Cancer Trust to contact me by (tick all that apply) *
Required
You will receive a welcome pack in the post upon signing up as a member, please confirm if you would like to receive this? *
Our newsletter is free to all members and is available in the following formats. Please select the format you would like to receive: *
Required
About you/your family
Please provide details of all family members affected by retinoblastoma:
Person 1
(Person 1) Full name: *
Your answer
Gender: *
Date of birth: *
MM
/
DD
/
YYYY
Relationship to you? *
Your answer
Date of diagnosis? *
MM
/
DD
/
YYYY
Bilateral or unilateral retinoblastoma? *
Treatment 1 *
Your answer
Date of treatment *
MM
/
DD
/
YYYY
Treatment 2
Your answer
Date of treatment
MM
/
DD
/
YYYY
Treatment 3
Your answer
Date of treatment
MM
/
DD
/
YYYY
Treatment centre? *
Person 2 (if applicable)
Full name
Your answer
Gender
Date of birth
MM
/
DD
/
YYYY
Relationship to you
Your answer
Date of diagnosis
MM
/
DD
/
YYYY
Bilateral or unilateral retinoblastoma?
Treatment 1
Your answer
Date of treatment
MM
/
DD
/
YYYY
Treatment 2
Your answer
Date of treatment
MM
/
DD
/
YYYY
Treatment 3
Your answer
Date of treatment
MM
/
DD
/
YYYY
Treatment centre
If you would like to be linked with other members and talk to other families about their experiences of childhood eye cancer, please tick below:
By typing your name below, you are signing your online membership form. *
Your answer
If providing details for your partner they also need to type their name below in order to sign the form.
Your answer
Data protection notice
The information which you provide in this form and any other information obtained or provided during your membership will be processed in accordance with General Data Protection Regulation 2018. By becoming a member of the Childhood Eye Cancer Trust you agree to your personal information being made available to employees of the Childhood Eye Cancer Trust, selected volunteers engaged for database work, and from time to time technical support staff from our CRM provider, subject always to compliance with the General Data Protection Regulation legislation. The personal data will be used for the purpose of processing your application, dealing with you as a member of the Childhood Eye Cancer Trust and furthering the stated aims of the charity. We may also use the information to contact you in connection with our fundraising activities. We will not pass your information on to third parties without your consent (unless required to by law), other than to those engaged in the delivery of our services and then only for a specified purpose. The Childhood Eye Cancer Trust is registered under the Data Protection Act 2018. A full copy of the privacy policy can be found on the CHECT website www.chect.org.uk.
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