Family Membership Form

Complete this form if your child is affected by Sturge Weber syndrome and you would like to apply for membership of Sturge Weber UK.

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


Family Membership Form
If yes, please give details
1. Parent / Guardian (primary contact for family) *
2. Name of spouse / partner
3. Street address *
4. Address (line 2)
5. Town / city *
6. County / state *
7. Postcode *
8. Country *
9. Telephone *
10. E-mail
11. Child's name *
12. Child's date of birth (dd/mm/yyyy))
13. Does child have a birthmark / port wine stain? *
  • Yes
  • No
14. If yes, what is its location?
15. Is your child affected by:
  • Epilepsy
  • Glaucoma
  • Hemiplegia
16. Has your child had any operations? *
  • Yes
  • No
17. If yes, please gve details
18. Does your child have any siblings? *
  • Yes
  • No
19. If yes, please give names and d.o.b.
20. Name of paediatrician / neurologist *