It does not matter how slow we go, so long as we do not stop!!!   HOME| ABOUT US|WAYS TO HELP|SAMAG ACTIVITIES| CONTACT US   INFO SAMAG   ATAXIA INFORMATION MEET SOME FAMILIES DISCUSSION BOARD SAMAG REGISTRATION RESOURCES   SAMAG Online Membership Registry Membership open to anyone who wish to be a SAMAG Member/Volunteer. Note: If patients are unable to register online on their own, their family members/guardians/ relatives or friends can register them with their consent. Name: Age: Sex: MALE        FEMALE Qualification: Occupation: E-mail address: Phone no: (OR) Moblie no: Address for Communication: Country: Zip Code: State: Do you have any Ataxia: Yes         No If Yes, select the type Select type of Ataxia Charcot-Marie-Tooth Disorder (CMT) episodic ataxia Gluten Ataxia Hereditary Spastic Paraplegia (HSP) Marie's Ataxia Olivopontocerebellar Atrophy (OPCA) Paraneoplastic Cerebellar Degeneration (PCD) Post-Infectious Ataxia Friedreich’s ataxia Spinocerebellar Ataxias (SCA's) (type 1 Spinocerebellar Ataxias (SCA's) (type 2 Spinocerebellar Ataxias (SCA's) (type 3 Spinocerebellar Ataxias (SCA's) (type 4 Spinocerebellar Ataxias (SCA's) (type 5 Spinocerebellar Ataxias (SCA's) (type 6 Spinocerebellar Ataxias (SCA's) (type 7 Spinocerebellar Ataxias (SCA's) (type 8 Spinocerebellar Ataxias (SCA's) (type 9 Spinocerebellar Ataxias (SCA's) (type 10 Spinocerebellar Ataxias (SCA's) (type 11 Spinocerebellar Ataxias (SCA's) (type 12 Spinocerebellar Ataxias (SCA's) (type 13 Spinocerebellar Ataxias (SCA's) (type 14 Spinocerebellar Ataxias (SCA's) (type 15 Spinocerebellar Ataxias (SCA's) (type 15 Spinocerebellar Ataxias (SCA's) (type 16 Spinocerebellar Ataxias (SCA's) (type 17 Spinocerebellar Ataxias (SCA's) (type 18 Spinocerebellar Ataxias (SCA's) (type 19 Mitochondrial ataxia Vestibular ataxia Ataxia Telangiectasia (A-T) Muscular dystrophies Other ataxias Do you have any Muscular Disorder: Yes         No Select type of Neuro Muscular Disease If Yes, select the type Congenital Muscular Dystrophy Distal Muscular Dystrophy Duchenne Muscular Dystrophy Emery-Dreifuss Muscular Dystrophy Facioscapulohumeral Muscular Dystrophy Limb-Girdle Muscular Dystrophy Myotonic Muscular Dystrophy Congenital Myotonic Muscular Dystrophy Oculopharyngeal Muscular Dystrophy Amyotrophic Lateral Sclerosis Spinal Bulbar Muscular Atrophy Spinal Muscular Atrophy Type 1 Spinal Muscular Atrophy Type 2 Spinal Muscular Atrophy Type 3 Congenital Myasthenic Syndrome Lambert-Eaton Syndrome Myasthenia Gravis Hyperthyroid Myopathy Hypothyroid Myopathy Dermatomyositis Non-MDA Diseases General Periodic Paralysis Myotubular Myopathz Nemaline Myopathy Central Core Disease Paramyotonia Congenita Myotonia Congenita Mitochondrial Myopathy - MERRF Metabolic Diseases Carnitine Deficiency Carnitine Palmityl Transferase Deficiency Inclusion-Body Myositis Polymyositis Debrancher Enzyme Deficiency Lactate Dehydrogenase Deficiency Myoadenylate Deaminase Deficiency Phosphorylase Deficiency Phosphofructokinase Deficiency Phosphoglycerate Kinase Deficiency Phosphoglycerate Mutase Deficiency Mitochondrial Myopathy - MNGIE Mitochondrial Myopathy - MILS Mitochondrial Myopathy - NARP Mitochondrial Myopathy - PEO Mitochondrial Myopathy - CPEO Pearson Syndrome Mitochondrial Myopathies Muscular Dystrophies Motor Neuron Diseases Inflammatory Myopathies Neuromuscular Junction Diseases Endocrine Myopathies Peripheral Neuropathies Other Myopathies "If you would like to report more information in brief like Patient’s symptoms/ Onset of disease/ Present condition, etc., provide it in the box below. Membership desired as: Ataxia patient (or) Patient's associate Volunteer SAMAG Representative What kind of support would you like to extend: Social (Volunteer) Medical Advice Any Other You can write to us with your past experience as a social worker in any field or what interested you to support SAMAG cause. (sam_ataxiaindia@yahoo.com). Applicant’s signature: (typing your name is accepted as your signature) I authorize SAMAG to Accept my details furnished in the registry form. Therefore all details furnished in the registry form is upto the best of my knowledge and consent, thereby understanding the terms of SAMAG. ALL INFORMATION SUBMITTED WILL BE KEPT CONFIDENTIAL CHECK FAQ ON SAMAG REGISTRATION Help us to share help 2008 © samataxiagroup.org Powered By INVOKE