Children's Resource Packs Order FormThank you for your interest in ordering our resources designed to support children impacted by stroke. Please fill out the form below to place your order. What is your relationship to the child or children who require the resources?(Required)Parent / Family memberHealthcare WorkerSchool Support StaffOtherWhat is the relationship between the child and the stroke survivor?(Required)How long ago was the stroke?(Required)How old is the person who has had a stroke?(Required)0-1819-2526-4041-66Over 67Your OrderPlease let us know the age of the child or children. We recommend ordering one book per child in the family. Professionals: We can provide one full pack as a reference pack for your ward, department, or unit for you to show to patients. You can then encourage them to order here or order on their behalf with their consent. Your OrderWhat is the age of the child needing the resources?(Required)N/A3 years old4 years old5 years old6 years old7 years old8 years old9 years old10 years old11 years old12 years old13 years old14 years old15 years old16 years old17 years old18 years oldWhat is the age of the second child who needs the resources? (if applicable)(Required)N/A3 years old4 years old5 years old6 years old7 years old8 years old9 years old10 years old11 years old12 years old13 years old14 years old15 years old16 years old17 years old18 years oldWhat is the age of the third child who needs the resources? (if applicable)(Required)N/A3 years old4 years old5 years old6 years old7 years old8 years old9 years old10 years old11 years old12 years old13 years old14 years old15 years old16 years old17 years old18 years oldWhat is the age of the fourth child who needs the resources? (if applicable)(Required)N/A3 years old4 years old5 years old6 years old7 years old8 years old9 years old10 years old11 years old12 years old13 years old14 years old15 years old16 years old17 years old18 years oldHEALTHCARE PROFESIONALS ONLY: A full pack for a stroke unit / professional settingN/A1 pack pleaseYour DetailsName First Last What's your job title? (professionals only)N/ANurse (including stroke specialist nurses)Stroke PhysiciansNeurologistPhysiotherapistOccupational TherapistSpeech & Language TherapistPsychologistSocial WorkerGPTeacherSchool Support StaffCharity WorkerOtherWe are sorry but we are only able to ship to the UK.Your Address(Required) Street Address Address Line 2 Address Line 3 City Post Code Your Email Address(Required) Email Address Confirm Email Address Contact Phone Number(Required)Would you like to join our mailing list?(Required) Yes No The Family Details (if you're ordering for someone else)Name of main contact in family First Last Contact Email Address Email Address Confirm Email Address Contact Phone NumberYour Address Street Address Address Line 2 Address Line 3 City Post Code Consent The family have given consent for me to pass on their detailsWhere would you like your resources to be delivered?(Required)Deliver to my addressDeliver to families addressDo you have any further comments or questions? Δ
