Member Registration Form

Please complete the following form and submit your information

Your name and address

*First name
*Last name
*Address 1
Address 2
*Town/City
*Postcode
*Email
Please provide us with at least one phone number below
Home Telephone
Mobile
Your relationship with the child/children with eczema
Other (please specify)

Details of other parent/carer of the child/children with eczema

If another carer of your child/children would like to receive email updates from EOS and to have the option to join our closed Facebook Group, then please complete their details here. This is optional and please make sure you have the person’s permission to give us their details.
Spouse/Partner First name

Spouse/Partner Last name

Spouse/Partner email

Relationship with the child/children with eczema

Other (please specify)

Your child/children with eczema

First name	Last name	Date of Birth (DD/MM/YYYY) ⓘ	Sex

Please let us know what the main eczema symptoms are and whether there are any key issues you would like help with

To help us understand the family circumstances better please let us know how many children without eczema there are in your family

Further Information

EOS is not a statutory service but at times we work with other professionals, including schools and Health visitors, to give the best support we can to your child/family. Please provide the following details for your child/children with eczema.
If you live in Scotland you must provide this information. This is in order for us to work within Scottish Government GIRFEC (Getting It Right For Every Child) requirements
Name of school (for school age children)

Health Centre/Health visitor (for any child not in school)

Reasons for joining (tick all that apply):

Information

Support

Meeting others

Where did you hear about us

Other (Please specify)

Consent to contacting you and storing your data

EOS can only deliver a service if we are able to contact you and store your data. Please read the statement below carefully and tick the box to give your consent

Gathering your data
By becoming a member of EOS you give consent for Eczema Outreach Support to gather and store relevant information regarding you and your child/children in order to deliver personalised services around your child/children’s eczema. Should you ever choose to make a donation to EOS this will also be recorded

Contacting you
By becoming a member of EOS you also give consent for Eczema Outreach Support to contact you in relation to your child/children’s eczema and our services. This contact can be by Post (e.g. to receive your welcome pack) Phone (e.g. to discuss support available for your child’s specific circumstances) Email (e.g. invitations to EOS events, newsletters, fundraising suggestions) All three forms of contact are vital in order for EOS to deliver a full service. If you have an objection to any of these forms of contact please get in touch with the EOS office before registering

Sharing your data
Your information might be shared with health care professionals, schools, or other statutory services relevant to your child’s eczema. EOS might also signpost you to other non-statutory organisations, but would only share your details with them if you agree to it. EOS will never share your details for commercial purposes

Retaining your data
EOS will retain the information provided by you for 3 years after you become an ex-member. You become an ex-member either when your youngest child with eczema turns 18 or you can at any stage request to be removed from the members list. After the 3 years EOS will delete all information we hold about you, except for limited statistical information, incl. your initials (not your full name), the first 2 letters of your postcode and the first letter of your child’s name

Withdrawing consent
You can at any point contact EOS to withdraw your consent for EOS to contact you. Withdrawing consent will limit the service EOS will be able to provide. If you withdraw from all 3 forms of communication you will be listed as an ex-member. You can also at any point withdraw your consent for your data to be stored. If you do EOS will delete all personal identifiable information we hold on you
To withdraw your consent please contact EOS either by email: info@eos.org.uk or by post: 129 High Street, Linlithgow EH49 7EJ
We conduct our business in compliance with the General Data Protection Regulation and are registered with the Office of the Information Commissioner under registration number ZA 131266
This must be ticked to authorise the registration

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