Trooper Registration

Username

Email

First Name

Last Name

Password

Password Again

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.

Date of Birth

Address Line 1

Address Line 2

City

Area *(Required)

Postcode

Telephone *(Required)

Alternative Telephone

Emergency Contact / 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....

Yes
No

Which limb are you deficient in? *(Required)

Would you like to tell us how and when you lost your limb(s)?

Mobility

Prosthetic
Wheelchair
Crutches
Both

How did you hear about FYF? (Required)

Photo Permission *(Required)

Yes
No
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.

Have you joined our No LIMBits Facebook Group? *(Required)

Yes
No