*Fields marked thus with an asterisk are compulsory fields.  The member is the person with Erb’s Palsy not their parents;  the form should be completed for the child if under 18; the [Hospital of Birth] field should include the town or address of the hospital for clarity.

    First Name*

    Last Name*

    Gender*

    Date of Birth*

    Parents/Guardians Names if under 18*

    Arm(s) Affected*

    Arm Details*

    Hospital of Birth*

    Delivery Method*

    Birth Weight (kg)*

    Addressee*

    Street*

    Town*

    District*

    County*

    Country*

    Postcode*

    Email Address*

    Mobile Number*

    Home Number*

    How did you hear about us*

    Sign up to Newsletter by post*

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