Trooper Registration

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?

What is your level of amputation? *(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