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Membership Request 
Title/Prefix:* 
First Name:* 
Last Name:* 
Address 1:* 
Address 2: 
Address 3: 
City: 
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Postcode:* 
Email:* 
Home Telephone: 
Mobile Telephone: 

Please give us details about the child you care for or support :

Child's First Name: 
Child's Last Name: 
Your Relationship: 
Date of Birth (dd/mm/yyyy): 
Gender: 
Details of Conditions: 

Please tell us about which Cerebra services to which you would like to subscribe :

Quarterly Newsbeat Magazine: 
Cerebra Library: 
Research eBrief: 
Cerebra regularly communicates with its members, by email, post and telephone. We aim to approach members with information that is of interest to them and by entering into membership you agree to be contacted in this way. Contact could be from either our Parent Support, Research or Fundraising departments. This regular communication can be terminated at any time by the member. We do not share your details with external agencies and all contact will be direct from Cerebra.
Page last updated: 07/06/2011 10:51 
Leigh's little hand... Awww 
© 2012 Cerebra | Registered charity No: 1089812 | Company Limited by Guarantee, registered in England and Wales 4336208