Update Your Membership

Member Details

Membership Type*

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

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

Is this a new membership?*

Yes
No

Member Name*

First Last

Second Member

Spouse, Partner, Guardian, etc.

First Last

Member Email*

Second Member Email

Member Primary Phone*

Second Member Phone

Mobile Number?*

Is this a mobile number?

Yes
No

Member Secondary Phone

Mobile Number?

Is this a mobile number?

Yes
No

Member Address*

Street Address Address Line 2 City State ZIP Code

Country*

Second Member Address (if different)

Street Address Address Line 2 City State ZIP Code

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.

Connection Details

Connection to MPS*

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

Second Connection to MPS

Who else in 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.

Relationship*

How are you related to your connection? ( i.e. parent, sibling, etc.) If you are an individual diagnosed with MPS or ML, please indicate self as your relation.

Syndrome*

Date of Diagnosis*

Please provide an approximate date of diagnosis.

Date of Diagnosis #2

Please provide an approximate date of diagnosis for your second connection.

Date of Diagnosis #3

Please provide an approximate date of diagnosis for your third connection.

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

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 Courage publication in printed format?*

Yes, I would like to receive a printed copy of Courage.
No, I would not like to receive a printed copy of 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

Please let us know if you are interested in opting into our remembrance program.*

Yes, I am interested in receiving bereavement materials throughout the year
No, I am not interested in receiving bereavement materials
This does not apply to me

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

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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