Survey - Register with PPMD - Parent Project Muscular Dystrophy

Are you a newly diagnosed family? (within the last two years?) Please register here. All others, please register your information below. Thank you!

Registration Information:


	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
	Street 1:
	City:
	State / Province:
	ZIP / Postal Code:
	Country:
	Yes, I would like to receive emails from Parent Project Muscular Dystrophy
	Yes, I would like to receive postal mail from Parent Project Muscular Dystrophy
	Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy

Please enter a user name and password for logging in when you return. You can use this password to update your information or receive personalized content.

*	User Name: Required	5 to 60 characters
*	Password: Required	12 to 99 characters
*	Repeat Password: Required

Question - Not Required - Cell Phone:

*

Question - Required - Please tell us your connection to Duchenne:

Question - Not Required - Would you like us to send you more information about Duchenne? Select the option that applies to you:

	Yes - Newly Diagnosed - Receive information on what steps to take next
	Yes - Already Diagnosed - Learn about the resources PPMD has available for families
	Yes - I am a Physical Therapist, Occupational Therapist, Doctor, or Researcher

International information requests must be sent via email to danielle@parentprojectmd.org

Question - Not Required - Would you like us to send you more information about our organization and it's programs? Select below:

Yes - I would like to learn more about the work PPMD is doing.

Question - Not Required - Where did you hear about PPMD? (required)

Question - Not Required - If "other" please provide additional information: