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
* Last name
* Address line 1
Address line 2
City
* Postcode /Zip code
* Date of Birth DD/MM/YYYY
* 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
* 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?

Person you care for

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

Name
Gender
Please let us know you relationship to the person you care for EG if you are a relative, paid carer, etc
Date of birth of person you care for DD/MM/YYYY
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
* We produce a magazine for Friends which is free each quarter. If you would like to receive please make sure you select below
I would like to:
What is your ethnic origin?
How did you hear about Ataxia UK?
I would like:
Gift Aid Declaration