Name

First Name

Last Name

Phone

(###)

###

####

Which one best describes you? *

I am living with muscular dystrophy.

I am a caregiver to someone living with muscular dystrophy.

I am a sibling to someone living with muscular dystrophy.

I am a medical professional who cares for individuals living with muscular dystrophy.

I am a grandparent to someone living with muscular dystrophy.

I work for an industry or organization whose mission supports individuals living with muscular dystrophy.

I care about someone living with muscular dystrophy but none of the above really describe me.

Your Age Group

I am less than 18 years of age.

I am at least 18 years of age.