Supporting Someone Registration Form

First name (required)

Surname (required)

How can we help right now?

Address line 1

Address line 2

Town

Postcode

Country

Your phone number

Your email address (required)

If you are in our Facebook group, or would like us to send you an invitation to join, you can add a link to your Facebook profile here to let us know who you are.

Do you have any disability or access needs that would be helpful for us to consider if we get in touch with you? For example if you struggle with mobility or need information in a larger font type for reading, you can tell us about that here.

Who is the person who has been diagnosed? The person diagnosed is... (required)

my childmy grandchildmy partnera family membermy friendmy work colleague or employeeother

Their first name (required)

Their surname (required)

What condition(s) have they been diagnosed with? (Please select all that apply.) (required)

Aplastic Anaemia (AA)Paroxysmal Nocturnal Haemoglobinuria (PNH)Fanconi Anaemia (FA)Dyskeratosis Congenita (or a Telomere Biology Disorder) (DC)Shwachman Diamond Syndrome (SDS)Myelodysplastic Syndrome (MDS)Diamond Blackfan Anaemia Syndrome (DBAS)Graft versus Host Disease (GvHD) Post-transplant lymphoproliferative disorder (PTLD)Other rare blood or bone marrow related disorderI’m not sure

Do they live at the same address as you? (required)

No. (Please complete the address section below.)Yes. (Skip the address section below.)

Their address line 1

Their address line 2

Their town

Their postcode

Their country

Their phone number

Their email address

How would they describe their gender?

FemaleMaleNon-binaryPrefer not to say

Their date of birth

When were they first diagnosed?

Their double birthday date. Many families celebrate the date of their stem cell or bone marrow transplant as a ’second birthday’. If you fill in this field, we’ll send them a Double Birthday Card on this date.

At what stage would you consider them to be at regarding their condition?

Recently diagnosed and seeking more information to help me understandOn Watch and Wait (pre-treatment monitoring)Receiving treatmentAwaiting or in recovery from a bone marrow transplantNavigating life with the conditionHave been living with the condition a long time and looking for ways to move forward with lifeDealing with longer term difficult outcomes

Would you be interested in being invited to volunteer in the following ways? (You can always change your mind later.)

Join online group discussions to share my opinions and improve healthcare services and treatmentHelping out on the day at an event near meHelping to organise an event near meTrain to be a moderator on our Facebook groupShare your story on our website (or in the magazine) for other people to read aboutTake part in a running event as a fundraiserTake part in another kind of sporting event as a fundraiserTake part in a cold water dip at Christmas timeRun a coffee morning in my local area

How did you hear about The Aplastic Anaemia Trust?

Recommended by a healthcare professionalRecommended by a friend or family memberSocial mediaOnline searchA poster, leaflet or booklet in the hospitalAt a conference or event

How would you like us to keep in touch?

EmailPhonePostWhatsApp

How would you describe your gender?

FemaleMaleNon-binaryPrefer not to say

Asian or Asian British

IndianPakistaniBangladeshiChineseAny other Asian background

Black, African, Caribbean or Black British

AfricanCaribbeanBlack British or IrishAny other Black background

Mixed or Multiple ethnic groups

White and black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed background

White

British (Scottish, English or Welsh)Northern IrishIrishGypsy or Irish TravellerAny other white background

Other ethnic group

ArabAny other ethnic backgroundPrefer not to say

Supporting Someone Registration Form

About you

We are here for you.

The person you’re supporting

The Aplastic Anaemia Trust and you

Your ethnicity and gender