Note: You will need to upload a copy of your child/adult's Dravet diagnosis letter in order to complete this form (PDF, Word, JPG).

Parent/Carer Your First Name*

Your Surname*

Your Email Address*

Your Telephone Number

Your Mobile Number

Home Address Address line 1*

Address line 2

City*

Postcode*

Country*

Relationship to person with Dravet Syndrome

Once you have registered, you will need a password to access your account.

Password*

Confirm Password*

Staying in touch

We* send out periodic newsletters, campaign and fundraising information, how do you want us to keep in touch with you? Please tick as many of options below as you’d like, to confirm your contact preferences

Post

Telephone

We try to support as many fund raising activities as we can, please tick this box if you wish for us to contact you to help in this.

As part of your account we send out birthday cards to your children, please tick this box to confirm if you wish to receive these