Family Member Registration Form
Which Programme are they being referred to?
Please select...
Children and Young People
Courses
Energy
Family Support
Mentoring
Outreach and Engagement
Vocation
Your Details
Title
First Name
Surname
Preferred Name/Known As
Are you under 18?
Yes
No
Date of Birth
Format DD/MM/YYYY
Age
Date of Birth
Format DD/MM/YYYY
Age
Email
Mobile Number
Home Address
House Name/Number and Street
Please start typing your address and select from the drop down.
Town/City
Postcode
What is your relationship to the person with a spinal cord injury?
Please select...
Partner/Spouse
Parent
Child
Adult Child
Sibling
Friend
Other
Are you their next of kin?
Yes
No
Parent/Guardian Details
As you are under 18, we need your parent's consent before we can support you. Please add their details below and we will send them a simple form to complete.
First Name
Surname
Email
Relationship to Person Being Referred
Please select...
Parent
Grandparent
Aunt/Uncle
Guardian
About the spinal cord injury
Who is the person with the Spinal Cord Injury?
First Name
Surname
Date of Birth
Family Session Information
My family member is being treated in a
Hospital
Spinal Cord Injury Centre
Which Spinal Cord Injury Centre is your family member being treated at?
SCIC Id
Which hospital is your family member being treated at?
Hospital Id
Service Id
Service Schedule Id
Which family support session do you wish to attend?
Service Session Id
Do you know the details of their injury?
Yes
No
Injury Details
Date of Injury
Year of Injury
You only need to complete this if you don't know the exact date.
Level of Injury
C1
C2
C3
C4
C5
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
S1
S2
S3
S4
Para
Tetra
Cauda Equina Syndrome (CES)
Please select all that apply - hold down the Ctrl button to select multiple options.
Injury Type
Please select...
Complete
Incomplete
Is a ventilator required?
Yes
No
Sometimes
Cause of Injury
Please select...
Medical Condition (e.g. illness, infection, tumour)
Surgical Complication
Assault or Violence
Fall
Road Traffic Collision
Sports Injury
Transverse Myelitis (TM)
Other
Not Known
Prefer Not To Say
Further details about the cause of injury
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Communication Preferences
We will try and contact you to support you using your preferred method, however, this may not always be possible.
Method
Marketing Preferences
Would you
like to be kept up to date on Back Up's latest news by email?
Yes
No
Contact Information