Community Groups Intake Form
You don't have to navigate your neuromuscular disease journey alone. As a member of the MDA Community, one of the many ways you can connect with others and share your personal story is by joining an MDA Community Support Group. Community Support Groups are a safe place to gather resources, interact meaningfully with others and exchange valuable information. To make sure that your experience is the best that it can be, we need to make sure that you have reliable internet access and a computer.
MDA membership is required to attend a community support group. Also, at this time, community support groups will only be offered in English.
What Community group do you want to register for?
Pediatric Community Support Group
Adult Community Support Group
ALS Community Support Group
Please take the time to answer the following questions so that MDA can learn a little bit more about you: The individual completing this form must be aged 18 or over.
Are you over the age of 18?
Yes
No
You have selected that you are not over 18. Please be aware that a parent or guardian over the age of 18 must complete this form and be present at the community group.
Are you a member of MDA?
Yes
No
Not sure
You have selected No or Not Sure for being an MDA Community Member. In order to register for a Community Group, you must be registered with MDA. Please click "Join MDA" at
https://www.mda.org/join-mda/form
.
Community Member's Information
Community Member First Name
Community Member Last Name
Community Member Email
Community Member Phone
Guardian Information
Guardian First Name
Guardian Last Name
Guardian Email
Guardian Phone
Relationship to Attendee
Please select...
Mother
Father
Parent
Foster Parent
Stepfather
Stepmother
Guardian
Daughter
Son
Spouse
Child
Wife
Family member
Parent-In-Law
Advisor
Attendant
Aunt
Benefactor
Boyfriend
Brother
Brother-In-Law
Caregiver
Child-In-Law
Colleague
Cousin
Coworker
Daughter-In-Law
Dependent
Emergency Contact
Ex-Husband
Ex-Spouse
Ex-Wife
Family
Father-In-Law
Fiance
Former Spouse
Foster Child
Friend
Girlfriend
Grandchild
Granddaughter
Grandfather
Grandmother
Grandparent
Grandson
Great Grandchild
Great Grandmother
Husband
Mentor
Mother-In-Law
Neighbor
Nephew
Niece
Other
Partner
Patient
Peer
Roommate
Sibling
Sibling's Child
Sibling-In-Law
Sister
Sister-In-Law
Son-In-Law
Step-Brother
Stepchild
Stepdaughter
Stepgrandchild
Stepgrandfather
Stepgrandmother
Stepparent
Step-Sibling
Step-Sister
Stepson
Teacher
Uncle
What is your/the community member's diagnosis?
How did you hear about the community group?
Clinic visit
Phone call
Resource Center
Website
Email
Newsletter
Quest magazine
Event attendance
MDA staff member
Social media
Other
To review our Privacy Policy, please click here:
https://www.mda.org/about-mda-privacy-policy
.
Contact Information