Membership Application Form

PINS provides information and support to families affected by Pelvic Girdle Pain (PGP) and is a charity registered in Sotland No. SCO 39222.
Membership is free and open to everyone aged 18 and over and our members come from throughout the UK and overseas.

All information provided will be treated in a confidential manner and your name will only be passed to our Regional Co-ordinators if permission is granted. No details are passed to any other organisation.

If you experience any difficulties completing this form please email info@pelvicinstability.org.uk or phone 01463 782801.
 

Title *
First Name *
Surname *
Gender *	FemaleMale
Date of Birth *
Address Line 1 *
Address Line 2
City/Town *
County/Region/State
Country *
Post Code/Zip Code *
Email Address *
Confirm Email Address *
Telephone
Can we pass your details onto our regional co-ordinators?	YesNo
Would you like to join our online forum exclusively for members of PINS ?	YesNo
The following questions are optional but will help us with our research and in planning and distributing information:
Q1 What is your interest in Pelvic Girdle Pain (PGP)? (Please indicate all that apply) I have Pelvic Girdle Pain A family member/ friend has Pelvic Girdle Pain (Please go to Q5) Other, please state
Q2 Is your Pelvic Girdle Pain a result of? (Please indicate all that apply) Pregnancy An accident A sports injury Other, please state
Q3 Are you:? Pregnant Post natal Never been pregnant
Q4 How long have you had symptoms of Pelvic Girdle Pain?
Q5 How did you hear about PINS?
Q6 Please feel free to add any additional comments or suggestions in the box below:
Enter the security number in the box - why?Unfortunately we have to do this to prevent the system being swamped by automated spam