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Membership Form

About You:

First name:
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Address:
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City:
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Postcode
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Phone number:
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Child/Young Person (CYP)
CYP1
CYP2
CYP3
CYP4
Name
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Gender
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DOB
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School

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Special
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Other
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Disability or additional needs

Physical Disability
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Sensory Impairment
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Mental Health Issues
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Learning Disability
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Complex Health Needs
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Autistic Spectrum Disorder
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Visual Impairment
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Social Commmunication Difficulties
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Life Limiting
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Other Information

How did you find out about the forum?
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Do you belong to any national support groups or networks?
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Which of the following does your family access?
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(Optional) If you are able, please help us to monitor our client base by completing this section so that we are able to target our services and funding more appropriately for the future:
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If there is any other information you feel we should know, please write it here:
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About You:

First name:
Field is required!
Last name:
Field is required!
Address:
Field is required!
City:
Field is required!
Postcode
Field is required!
Phone number:
Field is required!
Email address:
Field is required!

First Child

Name
Field is required!
Gender
Field is required!
DOB
Select a date
Field is required!

School

Mainstream
Field is required!
Special
Field is required!
Other
Field is required!

Disability or additional needs

Physical Disability
Field is required!
Sensory Impairment
Field is required!
Mental Health Issues
Field is required!
Learning Disability
Field is required!
Complex Health Needs
Field is required!
Autistic Spectrum Disorder
Field is required!
Visual Impairment
Field is required!
Social Commmunication Difficulties
Field is required!
Life Limiting
Field is required!

Second Child

Name
Field is required!
Gender
Field is required!
DOB
Select a date
Field is required!

School

Mainstream
Field is required!
Special
Field is required!
Other
Field is required!

Disability or additional needs

Physical Disability
Field is required!
Sensory Impairment
Field is required!
Mental Health Issues
Field is required!
Learning Disability
Field is required!
Complex Health Needs
Field is required!
Autistic Spectrum Disorder
Field is required!
Visual Impairment
Field is required!
Social Commmunication Difficulties
Field is required!
Life Limiting
Field is required!

Third Child

Name
Field is required!
Gender
Field is required!
DOB
Select a date
Field is required!

School

Mainstream
Field is required!
Special
Field is required!
Other
Field is required!

Disability or additional needs

Physical Disability
Field is required!
Sensory Impairment
Field is required!
Mental Health Issues
Field is required!
Learning Disability
Field is required!
Complex Health Needs
Field is required!
Autistic Spectrum Disorder
Field is required!
Visual Impairment
Field is required!
Social Commmunication Difficulties
Field is required!
Life Limiting
Field is required!
How did you find out about the forum?
Field is required!
Do you belong to any national support groups or networks?
Field is required!
Field is required!
(Optional) If you are able, please help us to monitor our client base by completing this section so that we are able to target our services and funding more appropriately for the future:
Field is required!
If there is any other information you feel we should know, please write it here:
If there is any other information you feel we should know, please write it here:
Field is required!

I consent to the information being used solely by Rainbow Parents Carers Forum. This information will not be shared with any other organisation without my permission. Please tick I accept the terms and conditions

You need to read and accept to our terms of service!
Submit
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