The Leanne Pero Foundation Membership Form
Please fill out our membership form below and one of our team will be in touch within the next 7 days to complete your sign up and offer a 1:1 call with you. Thank you, The TLPF Team x (This information is required for the purposes of your membership & will not be shared with any third parties without prior permission.)
First Name
Last Name
Email
Phone Number
Emergency Contact Name
Emergency Contact Relationship (optional)
Emergency Contact Number
Address
Town/City
County
Postcode
Date Of Birth (format DD/MM/YYYY)
12
Gender
Select an option
Prefer not to say
Female
Male
Non-binary
Transgender
Gender neutral
Ethnicity
Select an option
Other Ethnic Group
Black: African / Caribbean / British
Asian / Asian British
Multi-ethnicity
Do you consider yourself to be Disabled?
(or have a disability, impairment or long-term health condition (incl mental/physical health)
Yes
No
Prefer not to say
If yes, please tell us about this so that we can best support you during your membership with BWR
100
Do you consider yourself to be Neurodiverse?
(this could incl but not limited to Autistic spectrum, AD(H)D, OCD, Tourette’s, dyslexia, dyspraxia)
Yes
No
Prefer not to say
If yes, please tell us about this so that we can best support you during your membership with BWR
100
Cancer type / grade / stage
Please tell us the date(s) of your diagnosis
Please tell us a little about your current situation.
500
Please let us know how we can support you.
250
How did you hear about us?
Select an option
Social Media
Black Women Rising Magazine
Hospital/Medical team
Press/TV
Word of mouth
Google
I understand that by submitting this form, my personal details will be stored by The Leanne Pero Foundation in accordance with the Data Protection Act 2018 for the purpose of my membership & I consent to being contacted via email / phone.
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