Change of details form

About you (using the information we currently have on record)

Please state your connection to DEBRA (select all that apply): (required)

I am a DEBRA Member (i.e. someone who has EB or their family/carer)I fundraise for DEBRAI am a healthcare professional or researcherI donate to DEBRAI Gift Aid to DEBRAI attend DEBRA events

Title

First name (required)

Surname (required)

Email address (required)

Membership number (if applicable/known)

Supporter number (if applicable/known)

Previous phone number

Previous address

Post code (required)

New details (where applicable)

Title

Surname

Landline number

Mobile number

Email address

Address (please also state whether this is only for you or others in your household)

Post code

If you have any questions about the information we hold for you, please contact [email protected]. We will update your record with the information you have provided in this form. We respect your privacy and will not pass your details on to any third party without your permission. Full details of DEBRA’s Privacy Policy can be found at www.debra.org.uk/privacy

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