Event

Which event are you registering for? This has to be filled in.*

Patient Information

Country
State / Province*
Address
City
Parent Email*
Confirm Email*
Parent Phone*
Patient date of Birth
CF Patient
  • Yes
  • No
Wheelchair
  • Yes
  • No
Patient Condition(s)
School
Hospital
  • Evelina
  • GOSH
  • St Mary's Hospital
  • The Royal London Hospital
  • UCLH
Ward
  • 6C - PCCU
  • 7C - Gastro
  • 7D
  • 7E
  • 7F
  • Badger
  • Bear
  • Eagle
  • Elephant
  • Fox
  • Giraffe
  • Grand Union
  • Great Western
  • Koala
  • Lion
  • Miffy
  • Other
  • Peter Pan
  • Rainforest
  • Robin
  • Safari
  • Sky
  • T11
  • T11N
  • T11S
  • T12
  • T12N
  • T12S
  • T13
  • Westway
  • Macmillan Cancer Centre
  • Radiotherapy

Media Consent

Please confirm that you are happy for Spread a Smile to use certain in formation and media content about you in the manner described below, so that we can publicise the work that we are so passionate about, by consenting as follows

I am happy for my child and I to be f
Use Images
  • Yes
  • No
Name Use
  • Full Name
  • First Name Only
  • No Name

Parent Information

Mother's Name
Mother's Surname
Mother's Phone Number
Mother's Email
Father's Name
Father's Surname
Father's Phone Number
Father's Email

Sibling Information

Sibling 1 Name
Sibling 1 Date of Birth
Sibling 1 Gender
  • Male
  • Female
Sibling 2 Name
Sibling 2 Date of Birth
Sibling 2 Gender
  • Male
  • Female
Sibling 3 Name
Sibling 3 Date of Birth
Sibling 3 Gender
  • Male
  • Female
Sibling 4 Name
  • Sibling 4 Name
Sibling 4 Date of Birth
Sibling 4 Gender
  • Male
  • Female
Sibling 5 Name
Sibling 5 Date of Birth
Sibling 5 Gender
  • Male
  • Female

Data Protection

We collect and retain only the personal data necessary to carry out Spread a Smile's important work. That means we need to undertake various administrative tasks such as keeping records of donations, or to perform services like arranging trips for families. We would also like to be able to keep in touch with you so that we can tell you about our events and how your donations make a difference. Please tick the boxes below to indicate your preferences. Your consent may be withdrawn at any time.
We would like to contact you by email*
  • Opt in
  • Opt out
We would like to contact you by phone*
  • Opt in
  • Opt out
We would like to contact you by post*
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  • Opt out
Additional Comments

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