Username
Email
First Name
Last Name
Password
Password Again
Adult / Child
Adult
Child
Child Name/Age If you are the parent/carer of a child with an amputation or limb difference please tell us their name and age.
Which gender do you identify as?
Male
Female
Other
If you answered other above, please specify.
Date of Birth *(Required)
Address Line 1
Address Line 2
City
Area *(Required)
Postcode *(Required)
Telephone *(Required)
Alternative Telephone
Emergency Contact Number/ Relationship*(Required)
GP Name, Address & Tel No *(Required)
Do you have any form of Support Worker? e.g. Mental Health Care Team, Social Worker etc. *(Required)
Select an option
Yes
No
Would you like to tell us a bit more about the support you have available?
Which limb(s) are you deficient in? *(Required)
Right Arm
Right Arm Above Elbow
Right Arm Below Elbow
Left Arm
Left Arm Above Elbow
Left Arm Below Elbow
Right Leg
Right Leg Above Knee
Right Leg Below Knee
Left Leg
Left Leg Above Knee
Left Leg Below Knee
Would you like to tell us how and when you lost your limb(s)?
Which of the following do you use?
Prosthetic Limb
Wheelchair
Crutches / Sticks
None
How did you hear about FYF? (Required)
Photo Permission *(Required) From time to time we'll take photos & videos during our Clubs. Please tick to show you give us permission to use your photograph video for promotional purposes.
Yes
No
We record the information you give us in a secure database so that we can contact you and save you repeating your story. We will not give any details to anyone outside Finding Your Feet without your consent. Please let us know if you would prefer us not to save your information.
Yes
No
Have you joined our No LIMBits Facebook Group? *(Required)
Yes I'm already a member
No, not yet