MDI Child's Membership Form

Are you (please select),

Applying for membership

Membership Type

Person with muscular dystrophy age 17 or under

Annual membership runs from January to December.
All new membership applications will need to be approved by the Board.

How did you hear of MDI?

Other

General Details

Child's First Name

Child's Last Name

Street

Town/Area

City/County

Country

Postal Code

Phone

Mobile Phone

Email

Birthdate

If you have muscular dystrophy / a neuromuscular condition, please select the name of the condition from the dropdown menu in the box below so that we can maintain accurate information and tailor our services to your condition.

Type of Muscular Dystrophy

Type of Muscular Dystrophy (Continued)

Please select a more specific type if applicable.

First Emergency Contact & Parent/guardian contact information

First Name

Last Name

Street

Town/Area

City/County

Country

Postal Code

Phone

Mobile Phone

Email

Birthdate

Emergency contacts will be processed by MDI for the purposes of providing membership services to the child applying for membership above subject to MDI's data privacy policy.

Data Protection

I hereby acknowledge, by way of subscription, that my personal information will be processed by MDI for the sole purpose of matters of relevance to my membership of MDI

Yes, I agree

See data protection information here

Communication preferences

I agree to be contacted by MDI in the following ways regarding my membership. Please select yes or no for each option, indicating yes for at least one option

By phone

YesNo

By SMS

YesNo

By email

YesNo

Fundraising

Do you wish to receive communications from MDI regarding our upcoming appeals? We will communicate with you by your preferred methods captured above and you may opt out at any time. Details on how to opt out will be presented at the footer of, or within, any communication we issue to you on this basis

YesNo

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Payment

If you would like to pay now click Yes below or to skip payment, move on to submit form now

Yes

Do you require support or information from MDI?

Support call InformationAssistive TechnologyTransport to appointmentsJust want to receive emails, don't need additional support at the momentOther

Please provide additional information?

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