Primary Care Giver*:

Address*:

Postcode*:

Telephone Number*:

Email*:

Car Reg Number*:

Child's name*:

Amount of Children Staying*:
1234

Child 1 Age:

Child 2 Age:

Child 3 Age:

Child 4 Age:

Are they currently undergoing active treatment (Please select 'Yes' or 'No')*:
YesNo

If No, When Did They Receive Their Last Treatment?:

Consultant Name*:

Consultant Address*:

Consultant Postcode*:

Consultant Telephone Number*:

Consultant Email*:

Consultant Hospital*:

Nurse Name*:

Nurse Address*:

Nurse Postcode*:

Nurse Telephone Number*:

Nurse Email*:

Nurse Hospital*:

Do You Agree To The Terms & Conditions? (Please select 'Yes' or 'No')*:
YesNo

Keeping in touch

Please let us know how you wish to be contacted, you can change this at any time. Likewise, please do let us know if your contact details change. If you change your mind about any of these choices or have any concerns about any communications from us, please contact info@eilidbrown.co.uk. Your information will be held securely and confidentially in line with our Privacy Policy, available at www.eilidhbrown.co.uk/privacypolicy. I am happy for my data to be used to contact me about: (tick all that apply)

 The latest email newsletter from The Eilidh Brown Memorial Fund

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 Eilidh Brown House Holiday Bookings (for children with cancer and their families)

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