Membership Registration

Your Details

The fields below are required for making you an account on this website. Your username will be the email provided.

Your Name*

First Last

Contact Email*

Password*

Enter Password Confirm Password

Member Details

Member Name*

Please list the name of the primary member (parent/guardian/relative of a child with MPS or ML, or your name if you are an adult with MPS or ML and are registering yourself.)

First Last

Second Member Name

Spouse, Partner, Guardian, etc.

First Last

Member Email*

Second Member Email

Member Primary Phone*

Is this a mobile number?*

Yes
No

Member Secondary Phone

Is this a mobile number?

Yes
No

Member Address

Street Address Address Line 2 City State ZIP Code

Country*

Bio/Additional Info

Please list any additional family members, ages & relationships (if applicable), and/or any other relevant information you'd like us to know.

Is this a new membership?*

Yes
No

Website

Position

(if member of MPS Society)

Connection Details

Connection to MPS*

Who in your life deals with MPS or ML? Please provide his/her name. If you are affected with MPS or ML, please type your name.

Second Connection To MPS

Who else in our your life deals with MPS or ML? Please provide his/her name.

Third Connection to MPS

Who else in your life deals with MPS or ML? Please provide his/her name.

Syndrome*

Relationship*

How you are related to your connection(s)? ( e.g. parent, sibling, etc.) If you are affected, please indicate self as your relation.

Is the MPS/ML diagnosis confirmed for the individual?*

Yes, diagnosis confirmed
No, diagnosis is pending or uncertain
No, need assistance with confirmation process
N/A

Connection DOB*

Date of Birth of your first connection

Connection DOB #2

Date of Birth of your second connection

Connection DOB #3

Date of Birth of your third connection

Date of Diagnosis*

Approximate date of official diagnosis

Date of Diagnosis #2

Please provide a second approximate date of official diagnosis (if applicable).

Date of Diagnosis #3

Please provide a third approximate date of official diagnosis (if applicable).

Connection DOD

If your connection has passed, please indicate the date of his or her death.

Connection DOD #2

If your second connection has passed, please indicate the date of his or her death.

Connection DOD #3

If your third connection has passed, please indicate the date of his or her death.

Would you like to be included in our Membership Directory?*

Yes, I would like my contact info added to the Member Directory.
No, I would not like my contact info accessible to other members.

Would you like to receive our printed Courage publication?*

Yes, I would like to receive the printed Courage
No, I would not like to receive the printed Courage

Please check boxes below if you are interested in receiving information about the following services and opportunities.

Hosting a Fundraiser
Hosting Regional Family Gatherings
Connecting with Other Families
Courage Pages
Remembrance Pages
Family Support Programs
Board of Directors
Planned Giving

Membership Type*

Please indicate the type of membership for which you are registering.

Friends and Family (Free)
Professional ($75)
Corporate ($1000)

Would you like to make a donation?

Donation- Other

I would like to donate another amount.

Gift Designation

By default, your donation will go to the areas most in need. If you would like to designate your gift to a specific category, please indicate that below. Additionally, if you would like to make this donation in honor or in memory of someone, please also indicate this below.

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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First Choice
Second Choice
Third Choice

Membership Registration

Your Details

Member Details

Connection Details

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