CHECT Membership Form -  Young Person (aged 16-24)
*there is no charge for membership.
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Your details
Your first name: *
Your surname: *
First line of address *
County *
Postcode: *
Your mobile phone number: *
Your email address: *
Ethnicity *
Preferred language? (please type X if you prefer not to say) *
How we keep in touch
I am happy for The Childhood Eye Cancer Trust to contact me by (tick all that apply) *
Required
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
Date of birth: *
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What are your preferred pronouns - tick all that apply. (This helps us understand the best way to address you) *
Required
Date of diagnosis? (Approx) *
MM
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DD
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YYYY
Bilateral or unilateral retinoblastoma? *
Treatment 1 *
Date of treatment (Approx)
MM
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DD
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YYYY
Treatment 2
Date of treatment (Approx)
MM
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DD
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YYYY
Treatment 3
Date of treatment (Approx)
MM
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DD
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YYYY
Treatment centre? *
Have any other members of your family had retinoblastoma? *
If Yes please give details below (mother / father / grandmother / grandfather / brother / sister): *
Would you consider yourself to have a visual impairment? *
If Yes please give details below (certified sight impaired / partially sighted / other): *
Please tick below if you would like a support worker to contact you
By typing your name below, you are signing your online membership form. *
Data protection notice
We collect personal information about you in this form and in respect of your membership. We will continue to hold this data indefinitely unless you request its removal. You can find out more about how the Childhood Eye Cancer Trust processes your personal information in our Privacy Notice, available https://chect.org.uk/home-new-2/privacy/  
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