Become an Ambassador

Thank you for your interest in becoming a Spinal Research Ambassador.

Please complete the form below and we will be in touch soon!

If you have any issues with completing the form or require assistance please email community@spinal-research.org or phone 0203 824 7404

Thank you!

Your details

First Name

Last Name

Phone number

Address line 1

Town/City

Country

State

Province

County

Zip/Postal code

Date of birth

Application details

Please tell us how you could support Spinal Research by becoming an ambassador.

Please tell us if you have a special motivation to become an ambassador?

Please provide a short bio of yourself

Are you happy for us to share your bio on our website?

YesNo

Any other notes to support your application?

Upload your photo

Your connection to Spinal Research

Connection to Spinal Research

Injury level

Injury severity

How injury occurred

Year injured

Mobility impairment

T-shirt size

We will send you a Spinal Research t-shirt in your welcome pack, please advise of the size you would like. Please leave blank if you do not require a t-shirt.

T-shirt size

Communication preferences - NOT IN USE

We would love to keep you up to date with all the latest Spinal Research news and information. If you'd like to receive our updates please let us know how you'd prefer to receive them:

Phone

Text message

By submitting this form, you are agreeing to join our contact lists. We'll only send you information related to Spinal Research. Your privacy is important to us and we process your personal data in accordance with the UK GDPR and our Privacy Policy. You can unsubscribe at any time. For more information about our privacy practices, please visit our website.

Communication preferences

We would love to keep you up to date with all the latest Spinal Research news and information. If you'd like to receive our updates please let us know how you'd prefer to receive them:

Phone

Text message

By checking these boxes and submitting this form, you are agreeing to join our contact lists. We'll only send you information related to Spinal Research. Your privacy is important to us and we process your personal data in accordance with the UK GDPR and our Privacy Policy. You can unsubscribe at any time. For more information about our privacy practices, please visit our website.

Contact Information