PSPA Online Join Us Form for a Person living with PSP & CBD

Once we have received your form one of our Helpline Care Navigators will be in touch by email or phone. 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

Diagnosis Information

Diagnosis

Date of diagnosis (if known)

Date early symptoms first appeared (if known)

Pre PSP|CBD Diagnosis (if applicable)

Further Information

Date of birth

Sex

Pronouns

Ethnicity

Could you help us with our work?

Please select from the following options:

FundraisingVounteering

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

NCARDRS - If you live in England we can share identifiable information with the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS). This will only take place if you give us explicit permission to do this. NCARDRS is part of NHS Digital and collects data to get a better understanding of rare diseases and improve services and treatment through research and evaluation. The data collected includes your name, address, date of birth, diagnosis and who your doctor and consultant are. If you live in England, do you give permission for PSPA to share your identifiable data with NCARDRS? You can find out more information about NCARDRS here.

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