First Name *

Last Name *

Email *

Country *

Address *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Phone

I would like to be notified about drug trials and other research opportunities * YesNo

Are you a patient with FSHD? *

Gender *

Date of Birth *

Your age at onset of symptoms *

Your age at diagnosis *

Have you had genetic testing? What were the results? *

Do you have genetically related parents, siblings or children with FSHD? *

Do you have other genetic relatives - NOT parents, siblings, or children -- with FSHD? *

I am a ... (check all that apply) Relative of a PatientCaregiverPhysicianResearcherPhysical TherapistOther Clinician

I would like to join a local chapter of the FSHD Society

In addition to your local chapter, would you like to join the Early-Onset FSHD Chapter for parents of children with early-onset/infantile FSHD? YesNo

I am interested in (check all that apply) EducationPeer SupportResearchClinical TrialsFundraisingVolunteering

In order to develop tools to empower our diverse rare disease community, we ask you to please select the response that best reflects your race and ethnicity:

Gender Identity

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