Member Registration Form

Please complete the following form and submit

Your name and address

  
  
  
  
  
  
  
  
Please provide us with at least one phone number below  
  
  
  
  

Details of other parent/carer of the child/children with eczema

  
  
  
  
  

Please complete details of up to 4 of your children below (Tick symptoms that apply)

First name Last name Date of Birth
(DD/MM/YYYY)
Gender Has Eczema
(Select Yes or No)
Dry, Sensitive Skin Intense Itching Red, Inflamed Skin Recurring Rash Scaly Areas Skin Infections Allergies

If more than 4 children please summarise details of additional children in the box below.
  

Further Information

We work with schools and healthcare professionals to help our families and raise awareness of eczema. Please provide the following details for your child/children with eczema.  
  
  
  
Reasons for joining (tick all that apply):  
  
  
  
    
  
  
  

Getting in touch

We find it helps to talk to our members when they first join to find out how best we can help them in their particular situation.  
What is the best time to reach you (tick all that apply)  
Monday Tuesday Wednesday Thursday Friday
Morning
Afternoon
Evening
  
  

Data protection statement

We are committed to protecting the security and privacy of all personal information collected from you whilst providing a personalised service that keeps you up-to-date with information and services that meet your individual preferences and needs. We therefore conduct our business in compliance with applicable laws on data privacy protection and data security including the Data Protection Act 1998 and are registered with the Office of the Information Commissioner under registration number ZA131266.

We do not sell the personal information that we collect from you and will only use it to
- Provide you with information you request or we believe may be of interest to you
- To administer our membership records
- To improve our service or for statistical purposes
- To comply with a legal obligation to do so
  
  

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