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 Foundation 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 *