Membership

  • Persons aged 18 years and over living with Spina Bifida and/or Hydrocephalus

    I'm over 18
  • Child/Youth aged under 18 years living with Spina Bifida and/or Hydrocephalus

    I'm under 18
  • Affiliate membership for family, friends, supporters, or wider contacts connected to Spina Bifida and/or Hydrocephalus

    Affiliate membership
  • Please, enter your email adress

Membership Form – Child/Youth Under 18 years old who is living with Spina Bifida and/or Hydrocephalus

Your child’s details

Contact details

Title – please choose




  • First name

  • Middle name

  • Last name

  • Address line 1

  • Address line 2

  • Postcode

  • Town/City

  • Country

  • Eircode

Where does your child live? – Please choose from the list below:




Guardian details

Parent/Guardian 1

Relationship to child – Please choose:










Your age range: – Please choose:




Title – please choose






  • First name

  • Middle name

  • Last name

  • Address line 1

  • Address line 2

  • Town/City

  • Country

  • Eircode

  • Mobile number

  • Email address

  • Confirm email

Parent/Guardian 2

Relationship to child – Please choose:










Your age range: – Please choose:




Title – please choose






  • First name

  • Middle name

  • Last name

  • Address line 1

  • Address line 2

  • Town/City

  • Country

  • Eircode

  • Mobile number

  • Email address

  • Confirm email

Additional details about your child

  • Date of birth (DD/MM/YYYY)

  • Mobile number

  • Email address

  • Confirm email

Your child’s medical details

Medical Condition(s) – Please tick all that apply:







Ethnic origin - Please choose

Gender - Please choose


First language - Please choose


Do you have a shunt for Hydrocephalus management? – Please choose:

Any other medical information you wish to provide:

Your child’s mobility

  • My child is too young for mobility to be determined at present
  • Is your child a wheelchair user?



  • Is your child a motorised wheelchair user?



  • Does your child walk unaided?



  • Does your child walk with mobility aids?



Your child’s GP's details

  • GP's Name

  • GP's Phone Number

  • GP's Address 1

  • GP's Address 2

  • GP's Town / City

  • GP's County

  • GP's Eircode

Your child’s education

Is your child in education?

My child is too young for education at present

What level of education is your child currently at – Please choose:





Your child’s membership details

Community Healthcare Organisations (CHO) – Please choose your child’s area:









Where did you hear about SBHI? – Please choose:





SBHI has eight Branches covering many counties of Ireland. Are you happy for your details to be passed on to the local Branch if there is one in your area?


Have you completed this form on behalf of someone else?


Annual Report

Each year Spina Bifida Hydrocephalus Ireland produces an Annual Report for allmembers. In order to be as efficient as possible in sharing this document, please indicate if you would like a printed copy or a digital copy sent by email:



Photo consent

Spina Bifida Hydrocephalus Ireland host many events throughout the year for our members, some of which you or your family may attend. During these events we may take photographs, video recording or audio recording/quoted remarks which include members, their families, volunteers and staff. From time to time, these forms of media are used by Spina Bifida Hydrocephalus Ireland for printed publications or materials, electronic publications or presentations, the SBHI website or the SBHI Facebook pages.

In order for us to do this, we are obliged to ask you to select your preference below:

I hereby give permission to Spina Bifida Hydrocephalus Ireland to use photos/recordings which may include me, and/or my child and/or my family at various events within the Association throughout the year for promotional material or public information.

  • Please tick if applicable

I do not give permission to Spina Bifida Hydrocephalus Ireland to use photos/recordings which may include me, my child and/or my family at various events within the Association throughout the year for promotional material or public information.

  • Please tick if applicable

Membership fee information

There is no fee for Child/Youth under 18 years of age. Child/Youth under 18 years of age do not have voting rights.If Parent/Guardian wishes to become a Company Member and have voting rights, please complete an Associate Membership Form.

Preferred method of contact



Declaration

In accordance with Rule 3 – Articles of Association of SBHI: “A person with Spina Bifida and/or Hydrocephalus, or supporters, families and volunteers who support the work of SBHI, and who subscribe to the Rules and Bye-laws of SBHI, and who agree to be listed on the SBHI database are hereby defined as eligible for membership of SBHI.” I declare I will support the work of SBHI and I subscribe to the Rules and Bye-laws of SBHI and I agree to be bound by these Rules and Bye-laws as a SBHI member.

  • Print name

  • Signature

  • Date

(I agree) Please tick here to agree to our terms and conditions (full details below)

Terms and conditions

Data Protection

By filling in this form you agree to allow Spina Bifida Hydrocephalus Ireland to retain your information on a secure database.

Spina Bifida Hydrocephalus Ireland will ensure that your information is kept private and protected according to the Data Protection Act 1998. All the information we receive from you will only be used for research or collecting statistics, and to keep you up to date on Spina Bifida Hydrocephalus Ireland news and the benefits of being a Member. We will never pass on your details to another person or organisation without you agreeing to this.

Spina Bifida Hydrocephalus Ireland is committed to effective statistical recording using a bespoke database. We need this information to gauge the demand and use of services and to identify the need for new services. The statistics show that we are providing an essential service and also support new funding applications.

We recognise that all Service Users and Members should be able to access our services in confidence and we are committed to this principle. All staff and volunteers must ensure that no discussions relating to a Service User or Member takes place outside of the work environment. You can let us know at any time if you do not want Spina Bifida Hydrocephalus Ireland to make contact with you any longer. We will then ensure that your details are removed within 28 days of you telling us.

Breaches of Confidentiality

There may be occasions when it is necessary to breach confidentiality. For example, if a Service User or Member shares information about child abuse; where there is conflict of interest; or where there are legal implications. Spina Bifida Hydrocephalus Ireland recognises that any breach of confidentiality must be treated very seriously.

Any person whose data is held, has a right to access their file provided they give reasonable notice to the Organisation. There may be an administration charge for this service or a charge for providing copies.