About Ataxia

Join Ataxia UK

Joining Ataxia UK is free of charge and allows you to access all our services and resources. Please do fill out the form below with as much information as you can, as this will help us to support you. Information will be used only to monitor and improve our services to you and will not be passed on to third parties. Please contact us to find out about your rights under the Data Protection Act 1998.

Title *

First name *

Name *

Address *

Postcode *

Date of birth

/ /

Telephone

Mobile

Email
Please enter your email if you are happy for us to contact you in this way.

Please tell us about your ataxia or the ataxia of the person you care for *

Friedreich's ataxia
Cerebellar ataxia
Episodic ataxia
Other (if other please explain below)

Please tell us as much as you can about your ataxia or your connection to ataxia (eg if you care for someone) *

What is your connection to ataxia? *
If you care for someone with ataxia, please give us their details too. It is very important for us to keep our records as accurate as possible.

I have ataxia
I care for someone with ataxia
Other

Name of person you care for
Please tell us about the person you care for, if relevant.

Male or female

Relationship to the person you care for
Please let us know if you are a relative, paid carer, etc

Date of birth of person you care for

Would the person you care for like to be a Friend?

Any other information about your ataxia
(eg SCA number, your connection to ataxia)

When did your symptoms start? (Date/Year)

Neurologist (if relevant)

Hospital (if relevant)

Note

If you would like a medical information pack to be sent to your GP or a health professional please list their details below

Doctor's name

Doctor's address and hospital/clinic

Doctor's postcode

I would like to *
We produce a magazine for Friends which is free each quarter. If you would like to receive please make sure you tick below.

Receive the standard magazine by post
Large print
Audio version
Email (requires email address)
No magazine required

I would like to

Be put in touch with my local branch or group
Help set up a branch or group if none is available
I am already a member of my local group or branch

How did you hear about Ataxia UK?

I would like

To make a regular gift to Ataxia UK
Information about fundraising for Ataxia UK
Information about leaving a gift in my will

Gift Aid
I am a UK taxpayer and I would like Ataxia UK to treat all donations I have made since 6 April 2004 and all donations I make from the date of this declaration until I notify you otherwise, as Gift Aid donations.

* Denotes required field.

Ataxia UK, Lincoln House, Kennington Park, 1-3 Brixton Road London SW9 6DE, United Kingdom © Ataxia UK 2009. Ataxia UK works across the whole of the UK and is a charity registered in Scotland (no SC040607) and in England and Wales (no 1102391) and a company limited by guarantee (4974832).
Telephone: 020 7582 1444 office@ataxia.org.uk

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HELPLINE: 0845 644 0606

Join Ataxia UK