Connection Scheme Form

Contact Information

Country
Email*
Confirm Email*
Phone
Preferred Method of Contact with Connections - Please choose ONE (If you are outside of the UK we would recommend you use email for cost effective communication)*

Connection Details

In order to connect you with the most appropriate members, we ask for a range of health and personal information which under the Data Protection 2018 is considered sensitive. Your data will only be used to allow us to connect you with other members who have had similar experiences. Do you consent to your data being collected and processed for this purpose:

Connection-Consent*
Your Gender*

Tell us about some of the outcomes that have been experienced post encephalitis

Behavioural Consequences
Cognitive Consequences
Emotional Consequences
Senses Consequences
Physical Consequences
Psychiatric Consequences
Homeostasis Consequences
Other Consequences
Difficulties Experienced Post Diagnosis
Membership*

It is important to us to be able to engage with you and keep you up to date with the latest news about encephalitis and our work. This might include information about fundraising and research or other aspects of our work that help us meet our primary aim of improving the quality of all lives affected by this often-devastating condition. Please tell us how you prefer to hear from us and the different ways that we can keep in touch with you.

Consented to be contacted via*

By completing and submitting this form you are confirming you have understood the terms and conditions of and are agreeing to be part of the Scheme which involves the sharing of your information with others within the scheme. By submitting this form you are also agreeing to the Encephalitis Society holding the information contained within on our database, this information will be kept in accordance with the Data Protection Act 2018. You have the right at any time to request your information be deleted from our database or to be removed from the scheme, please contact the Society directly. The Encephalitis Society cannot be held responsible for the content of interaction between Connections (others signed up to this scheme). The Society maintains the right to deny or restrict access to this scheme as deemed necessary in particular due to a breach of our communication guidelines by an individual.

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