Membership Type*

Contact Information

Confirm Email*

In order to process your membership, 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 process your membership. Do you consent to your data being collected and processed for this purpose:

Consent to process special data
Date of Birth (dd/mm/yyyy)
Are you interested in finding out more about volunteering
About you*

Encephalitis Details

Please complete the details below if applicable:

Name of Person Affected
Date of Birth of Person Affected (dd/mm/yyyy)
Age at Diagnosis
Age at Second Diagnosis (Please leave blank if not applicable)
Deceased Date (Please leave blank if not applicable)
Other Type (Not Listed Above)
Problems Note

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 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
Additional Comments


Powered by eTapestry