Registration

Please fill in the form below if you would like to be a part of the Umbrella Network.


Your Details
First Name:
Last Name:
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Child's Details
Child's Name: (optional)
DOB: (optional)
Child Attends: (optional)
Child's Diagnosis: (optional)
Other Siblings (optional)
Childs Name:
Childs Name:
Childs Name:
Childs Name:
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PHOTOGRAPHY PERMISSION

The Umbrella Network occasionally uses photography for publicity purposes. We
would like your permission to use the photograph/film of you/or your relative
for possible inclusion in our publications, website and other print media.
The image(s) will remain the property of The Umbrella Network and will be
used for the designated purpose of promoting The Umbrella Network only.
Please tick the appropriate response.


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I recognize that by placing a tick in the appropriate response that this is
recognized as authorizing the above.

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