CHECT Membership Form - Family
*If under 16 years of age this form must be completed by a parent or guardian.

**there is no charge for membership.
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Your contact details
Title *
Required
Your first name: *
Your surname: *
Partner's title and full name:
First line of address *
County *
Postcode: *
Your home phone number:
Your mobile phone number: *
Your email address: *
Your ethnicity *
Your partners mobile number:
Your partners email address:
Your partner's ethnicity *
Preferred language? (please type X if you prefer not to say) *
What are your preferred pronouns - tick all that apply. (This helps us understand the best way to address you)
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: *
Date of birth: *
MM
/
DD
/
YYYY
Relationship to you? *
Their ethnicity *
Date of diagnosis? *
MM
/
DD
/
YYYY
Bilateral or unilateral retinoblastoma? *
Treatment 1 *
Date of treatment (Approx) *
MM
/
DD
/
YYYY
Treatment 2
Date of treatment (Approx)
MM
/
DD
/
YYYY
Treatment 3
Date of treatment (Approx)
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. *
If providing details for your partner they also need to type their name below in order to sign the form.
Data protection notice

We collect personal information about you and your child in this form and in respect of your membership. We will continue to hold your data indefinitely unless you request its removal. We will contact your child when they are 16 for consent to hold their data. 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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