Adult Membership Form

Complete this form if you are an adult affected by Sturge-Weber syndrome and would like to become a member of Sturge-Weber Foundation UK.

All data is confidential and treated in compliant with the Data Protection Act.


Adult Membership Form
Questions marked by * are required.
1. Name: *
2. Occupation
3. Name of spouse / partner (if any)
4. Street address *
5. Address (line 2)
6. Town/city *
7. County / State *
8. Postcode *
9. Country *
10. Telephone *
11. E-mail
12. Date of birth
13. Do you have a birthmark / port wine stain? *
14. If yes, where is it located?
15. Check boxes if you are affected by:
  • Epilepsy
  • Glaucoma
  • Hemiplegia
16. Name of consultant / neurologist *