South West Wales Brain Injury Group Membership Sign Up Form

Please use this form if you would like to sign up to free membership of the SWWBIG

Membership is free of charge.

Your details will be used to enable the Group to meet its objectives:

To provide a forum for individuals with an interest in acquired brain injury (ABI).
To educate and increase knowledge about ABI locally.
To encourage development and dissemination of good practice about ABI locally.
To contribute to the development of local ABI networks.

For more information about how we use your data, please refer to our Privacy Policy. If you would like a paper copy of this Policy, please let us know.

You are able to cancel your membership at any time.

Thank you for signing up to become a member.

All enquiries- please contact swwbig@gmail.com / 01792 525578.

This form data will be held within survey monkey for no longer than 60 days.

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* 1. Title

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* 2. First Name

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* 3. Surname

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* 4. Please tell us your link with Brain Injury in South West Wales (Please tick)

Professional

Personal

South West Wales Brain Injury Group Membership Sign Up Form

Please use this form if you would like to sign up to free membership of the SWWBIG

Question Title

* 1. Title

Question Title

* 2. First Name

Question Title

* 3. Surname

Question Title

* 4. Please tell us your link with Brain Injury in South West Wales (Please tick)

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* 5. Job Title/Occupation (if professional)

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* 6. Organisation (if professional)

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* 7. Contact Telephone Number (optional)

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* 8. Contact Email Address (mandatory for membership- we do not use other methods of contact with our members- please check spelling carefully)

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* 9. Please Retype Email Address