If you would like to register with the TBPI Group please fill in this form and click on the SUBMIT button. The form is in three parts; the first part is for everyone to fill in. The second part is only for people with a BPI , and the last part is for other visitors, for example, parents of someone with a BPI.
Please enter your name
Email address
Address line one
Town or City
Zip or Postcode
Country initials e.g. "U.K."
Date of birth
Your gender
Do you have a Brachial Plexus injury?
If you do not have a BPI yourself, but you would like to take part in any future surveys, please go to this section > CLICK HERE
If you clicked on 'yes' to the last question, Please answer the following questions.
Please click on the button that best describes your injury
Date your injury ocurred or was first noticed or diagnosed
Would you be happy to take part in any on-line surveys on this site about BPI ?
THANKS for filling in the form! Click HERE to go to the RESET and SUBMIT buttons and to read the privacy statement.
PRIVACY STATEMENT; The authors of this website and the Committee that runs it promise that ANY information collected in this form will NOT BE PASSED ON TO anyone. ALL data will be kept on a secure computer that is never connected to the internet. We shall of course comply with the Data Protection Act (U.K.) 1998 if it applies.
CLICK the reset button to clear the form and start again..
CLICK the submit button to send your answers.
These next few questions are for all visitors who want to register but do not have a Brachial Plexus injury.
Are you one of the following; (Please click one of the statements in the dropdown list below)
Age of your child/friend
Date of injury to your child/friend
Thanks for filling in the form! Please read the Privacy notice below.
