Register with Us

REGISTRATION FORM

Please provide as much of the data below as you can, and then sign the Declaration below, giving your explicit permission for GIST Cancer UK (GCUK) to hold the same.

Please provide your email address because this is the best way for us to stay in touch. Also provide a contact telephone number as backup because email can be unreliable. If you are a patient or carer, please also indicate if you would like to be enrolled into our private patient/carer online email forum where you are free to exchange information with other patients/carers and be updated about patient conferences, events and new treatment trials.

* = required fields.

Title *

First Name(s) *

Surname *

Status/Role (Patient, Carer, Medical Professional, Hospital Rep, Other) *

Email address *

Phone Number *

Alternative Phone Number

Address *

Post Code *

Country

If you would like to, please write your message, question, or further information about your situation below...

For Patients/Carers: I would like to join the GIST Cancer UK private email forum:
YESNO

DECLARATION

I give consent for GIST Cancer UK to hold the above data concerning myself, (and as a patient I also give GIST Cancer UK my permission to retain any further personal data that I might supply which is relevant to my GIST journey and, if required, to use this anonymously in the furtherance of its mission).

Declaration Signed By (name) *

Date Signed: (dd/mm/yyyy) *

* Human test : Which is bigger, 2 or 8?