PSPA Online Join Us Form for Carers, Family Members & Friends

Once we have received your form one of our Helpline Care Navigators will be in touch by phone or email. If you would like any support filling out the form please contact the helpline on 0300 0110 122.

Contact Details

Salutation

First Name

Last Name

Preferred Name (nickname)

Address Street

Address Town / City

Address County

Address Postcode

Email Address

Mobile Number

Home Phone

Preferred Phone

How did you hear about PSPA

Introduction From

Further Information

Sex

Pronouns

Ethnicity

Person Living with PSP|CBD Information

Name of the family member or person living with PSP|CBD

Date of birth

Person with PSP|CBD Ethnicity

You are their:

Your relationship to that person

Diagnosis

Date of diagnosis (if known)

Date early symptoms first appeared (if known)

Pre PSP|CBD Diagnosis (if applicable)

Please add the person living with PSP|CBDs address if different from above:

Person with address Street

Person with Address Town / City

Person with Address County

Person with Address Postcode

Could you help us with our work?

Please select from the following opportunities:

FundraisingVolunteering

Communication Preferences

We would like to continue to keep in touch with you to tell you about the vital work we do for people with PSP or CBD, our fundraising activities, and opportunities to support us.

Please select all the ways you would like to be contacted:

I would like to receive communications by email

I would like to receive communications by post

I would like to be contacted by phone

I would like to receive invites to any PSPA Support Groups

I do not wish to be contacted by PSPA

You can change your marketing options at any time by contacting us by email: consent@pspassociation.org.uk; telephoning us on 01327 322 410; or writing to us at PSPA, Margaret Powell House, 415a Midsummer Boulevard, Milton Keynes, MK9 3BN.

Registered charity number England and Wales 1037087 and Scotland SCO41199

Contact Information