Brainwave Registration Step 1 of 4 25% Please note: Any child up to the age of 18, with a diagnosed neurological condition, is eligible to register with Brainwave. To join, and have access to our free family events, newsletters and our Equipment and Therapies Funding program, please fill in the form below. All information provided is treated as confidential. Parents/Guardians detailsMother*First nameSurnameEmailMobile FatherFirst nameSurnameEmailMobile Address* Street Address Address Line 2 City State Postcode How did you hear about Brainwave* Hospital Google Media Family and friends Child with neurological conditionChild*First nameSurnameDate of BirthGender (M / F) Child's neurological conditions* Brain tumor Epilepsy Acquired brain injury Cerebral palsy Muscular dystrophy Multiple sclerosis Stroke Hydrocephalus Encephalitis Other Feel free to provide additional information relating to your child's neurological condition that may help Brainwave with planning family events*Mobility aids Wheelchair Walking frame Standing frame Assistance dog Other Type of Assistance dogOther mobility aid type Hospital/Health Service DetailsTreating Hospital/Health Service*Neurologist / Specialist*Telephone*I consent to Brainwave contacting the treating hospital/health service/paediatrician to verify my child’s neurological condition* I consent Brainwave runs a series of free family events throughout the year. To ensure all family members are included please provide sibling details for our records. Sibling detailsFirst nameSurnameDate of birthGender (M / F) Any other family members living with you?First nameSurnameRelationship to childGender (M / F) Brainwave programs are funded through our own initiatives and generous support received from corporate organisations and philanthropic trusts. As part of our reporting, Brainwave seeks photos and stories of our registered children and families from these events to highlight the value and benefits of our programs. In addition, photos and stories are used in Brainwave promotional materials including the website and social media. Please indicate your willingness to participate in this process by ticking the boxes below: * I am happy to contribute a testimonial/personal story about my experience at a Brainwave family event. * I consent to my child/family being photographed at Brainwave family events NameThis field is for validation purposes and should be left unchanged.