Community Connection Programme
Name
Email address
County
Phone number
Date of Birth
Please share why you would like to join the programme
?
Relationship to member
I am a partner of a person with a neuromuscular condition
I am a parent of a child with a neuromuscular condition
I am a member with a neuromuscular condition
Other
If other please specify
Members name
Do they have a neuromuscular condition?
Please select...
Yes
No
What type of neuromuscular condition?
Does the member have children?
Please select...
Yes
No
Child/Children's names and DOB
Do any of your children have a neuromuscular condition?
Please select...
Yes
No
What type of neuromuscular condition does your child or children's have and what's the child's name?
By ticking this box below you are confirming your permission to be added into the wider Community Connection WhatsApp group for all members who sign up?
At any time and are under no obligation to continue contact.
MDI may contact you to gather feedback around your experience of the programme.
Yes
By ticking this box you are confirming you understand that
MDI will only add you to the WhatsApp group we will not be responsible for any additional meetings or communications. MDI are not liable for any conversations or anything shared in this WhatsApp group. To ensure we can add new members a member of MDI staff will remain in the group, however will not be monitoring or partaking in the group chat.
Yes
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