123 Your details We will use the details you provide to send your Brainy Bag and ensure the contents are appropriate for your child. If you are happy to share any health information with us, we will use this to provide relevant information and support, monitor our services and make improvements in future.Title(Required)Please select…MrMsMissMrsMxDrProfSirDameLordLadyBaronessRevRt. HonCllrDukeDuchessCmdrFirst name(Required) Last Name(Required) Email address(Required) Phone number(Required)Please note: Brainy Bags are available for all children and young people with a brain tumour diagnosis within the United Kingdom only.Address(Required) Address Line 1 Address Line 2 City County Postcode What is your relationship to the child with a brain tumour?(Required)Please select…ParentLegal GuardianGrandparentSiblingRelativeHealthcare ProfessionalHow did you hear about our brainy bag?(Required)Please select…The Brain Tumour Charity websiteEmail from The CharityFrom The Brain Tumour Charity staff memberThe Grey MattersSocial MediaSearch engine (i.e. Google)Through a family member/friend/colleagueRecommended by a health professionalRecommended by another charityOtherPlease tell us how you heard about our Brainy Bag The child’s detailsChild's first name(Required) Child's last name(Required) Date of birth(Required) DD slash MM slash YYYY Child's brain tumour type (if known)Acoustic neuroma (also known as vestibular schwannoma)Anaplastic astrocytomaAstrocytomaAT/RT (atypical teratoid/rhabdoid tumour)Brain stem gliomaChoroid plexus tumourCNS lymphomaCraniopharyngiomaDiffuse astrocytomaDIPG (also known as diffuse midline glioma)Embryonal tumours (including PNETs)EpendymomaFamilial tumour syndromes (including NF1/2 and schwannomatosis)Fibrillary astrocytomaGangliogliomaGerm Cell TumourGlioblastoma (GBM)HaemangioblastomaMedulloblastomaMeningiomaMetastatic Brain TumourMixed GliomaOligodendrogliomaOptic nerve gliomaPilocytic AstrocytomaPineal region tumour (including pineoblastoma)Pituitary tumourSchwannomasSpinal cord tumourUnspecified gliomaAnaplastic oligodendrogliomaLi-FraumeniPineoblastomaOtherUnknownPlease enter the type of tumour(Required) Child's tumour grade (if known) Low Grade (1-2) High Grade (3-4) Child's date of diagnosis DD slash MM slash YYYY Recency of your child's diagnosis Within the last 2 weeks Within the last 4 weeks More than 4 weeks ago Where is your child's primary hospital?Please select…Aberdeen – Aberdeen Royal InfirmaryBelfast – Royal Victoria HospitalBirmingham – New Queen Elizabeth HospitalBristol – Bristol Royal InfirmaryBristol – Frenchay HospitalBristol – Southmead HospitalCambridge – Addenbrooke's HospitalCardiff – University Hospital of WalesCoventry – University Hospitals Coventry and WarwickshireDenbigshire – Glan Clwyd HospitalDerby – Derby Royal InfirmaryDublin – Beaumont HospitalDundee – Ninewells HospitalEdinburgh – Edinburgh Cancer Centre at Western General HospitalExeter – The Royal Devon and Exeter HospitalGlasgow – Queen Elizabeth HospitalGlasgow – Southern General HospitalGloucester – Gloucestershire RoyalHull – Hull Royal InfirmaryIpswich – Ipswich HospitalLeeds – Leeds Gamma Knife Centre (Nova Healthcare)Leeds – Leeds General InfirmaryLeeds – St James's University HospitalLeicester – Leicester Royal InfirmaryLincoln – Lincoln County HospitalLiverpool – The Clatterbridge Cancer CentreLiverpool – The Walton Centre for Neurology and NeurosurgeryLondon – Barts and London Centre for NeurosciencesLondon – Bupa Cromwell HospitalLondon – Charing Cross HospitalLondon – Guy's HospitalLondon – Hammersmith HospitalLondon – Harley Street University College HospitalLondon – King College HospitalLondon – Lister HospitalLondon – Moorfields Eye HospitalLondon – National Hospital for Neurology and NeurosurgeryLondon – Royal Free HospitalLondon – Royal London HospitalLondon – Royal Marsden HospitalLondon – St. George's HospitalLondon – St. Mary’s HospitalLondon – St. Thomas’ HospitalLondon – The Cyber Knife CentreLondon – University College HospitalLondon – Wellington’s HospitalMacclesfield – Macclesfield District General HospitalManchester – The ChristieManchester – The Royal Manchester Children’s HospitalMiddlesbrough – James Cook University HospitalNewcastle – Freeman HospitalNewcastle – Royal Victoria InfirmaryNorwich – Norfolk and Norwich HospitalNottingham – Queens Medical CentreOxford – John Radcliffe HospitalPlymouth – Derriford HospitalPoole – Poole General HospitalPreston – Royal Preston HospitalRomford – Queen’s HospitalSalford – Salford Royal HospitalSheffield – Royal Hallamshire HospitalSouthampton – Southampton General HospitalStoke – University Hospital of North StaffordshireSunderland – Sunderland Royal HospitalSutton – Royal Marsden HospitalSwansea – Morriston Hospital of SwanseaSwansea – Singleton HospitalSwindon – The Great Western Hospital SwindonTaunton – Mugrove ParkTruro – The Royal Cornwall HospitalWest Sussex – Hurstwood ParkWolverhampton – New Cross HospitalYork – The York HospitalCardiff – Velindre HospitalUnknown Keeping in touch We’ll send your child’s Brainy Bag shortly, however we’d also love to keep you up-to-date on how we are making a difference, this will include information about research, support services and how you can get involved, for example by fundraising, campaigning or volunteering.Can we keep you up to date via email?(Required) Yes No You can change your contact preferences at any time by emailing [email protected] or calling 01252 237792. Your details are held on our secure database and we promise never to share them with any other organisation for their marketing purposes. You can find out more in our Privacy PolicyHiddentbtc_utm_source Hiddentbtc_utm_medium Hiddentbtc_utm_campaign Hiddentbtc_utm_term Hiddentbtc_utm_content Hiddentbtc_ga_client_id
