REGISTRATION FORM - Healthcare Professional or Researcher

REGISTRATION FORM - Healthcare Professional or Researcher
Register with Muscular Dystrophy Canada to stay up to date on all our initiatives, news and opportunities to support the neuromuscular community. By registering with Muscular Dystrophy Canada, you will hear about research funding opportunities, have access to NMD-specific training and education, have opportunities to contribute to Muscular Dystrophy Canada-led research, learn about opportunities for multi-disciplinary collaboration, have access to knowledge translation activities, and much more.
APPLICANT INFORMATION

(To be completed by Healthcare Professional or Researcher)
EnglishFrench
EnglishFrench
DrMrMrsMsMissOther
Applicant name*
(First name / Initials / Last name)
Address
(Suite / Street / Street Name)
City
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Primary Academic or Clinical Institute/Site
Telephone
Email*
(mandarory if available)
I am a Healthcare ProfessionalI am a ResearcherOther
All neuromuscular disordersCongenital muscular dystrophiesDuchenne/Becker muscular dystrophiesEmery-Dreifuss muscular dystrophyFacioscapulohumeral muscular dystrophyHereditary ataxiasHereditary motor & sensory neuropathies (including CMT, HSAN, GAN)Hereditary myopathies (congenital, distal, metabolic and others)Immune-mediated myopathiesImmune-mediated neuropathiesLimb-girdle muscular dystrophiesMitochondrial muscle disordersMotor neuron disorders (including spinal muscular atrophy)Myotonic syndromes (including myotonic dystrophy)Neuromuscular junction disordersOculopharyngeal muscular dystrophyOther
YesNoN/A
BiomarkersCardiac involvement in neuromuscular disordersCell-based modeling & screeningCognitive and behavioral aspects of neuromuscular disordersDNA & RNA repeat disordersEpidemiology and natural history studiesGene targeting therapy including gene transfer, antisense oligonucleotides and gene editingGenetic diagnosisIn vivo modelsInflammation, immune mechanismsMetabolic disturbances in neuromuscular disordersNewborn screeningNuclear membraneOutcome measures for neuromuscular disordersProtein homeostasisQuality of life/patient preferencesRegeneration & repairRespiratory involvement in neuromuscular disordersTechnology in healthcareTissue bioengineeringOther
AudiologistCardiologistChiropractorDNA & RNA repeat disordersEndocrinologistFamily Physician/General PractitionerGenetic CounsellorGeneticistNeurologistNurseNutritionist/DieticianOccupational TherapistOrthotistPediatricianPersonal Support WorkerPhysiatristPhysiotherapistPodiatristPsychiatrist/Psychologist/Mental Health ProfessionalRespiratory TherapistRespirologistRheumatologistSocial WorkerSpeech Language PathologistOther
Adult CarePediatric CareBoth
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YesNo
8 How did you hear about Muscular Dystrophy Canada?
Muscular Dystrophy Canada collects personal information for a variety of purposes including the delivery of services, fundraising, quality management, research, billing and meeting legal and regulatory requirements. Muscular Dystrophy Canada utilizes several safeguard measures to protect personal information and keep it confidential and will not share any personal information with any third parties unless it is directly related to the delivery or enhancement of the services that Muscular Dystrophy Canada provides or unless a Canadian law requires it. Muscular Dystrophy Canada has guidelines and procedures to prevent unauthorized access and to govern the destruction of personal information. The full Muscular Dystrophy Canada Personal Information Protection (Privacy) Policy is available on the Muscular Dystrophy Canada website or by request. For more information about our privacy policy or Muscular Dystrophy Canada, please call 1-800-567- 2873 or visit muscle.ca.
SUBMIT COMPLETED APPLICATION BY:
Mail: 4211 Yonge St, Suite 316, Toronto, ON M2P 2A9

Fax: 1-866-726-8732

Email: registration@muscle.ca
MDC25HCPRegistrationForm-E

Updated 2025/11/04
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REGISTRATION FORM - Healthcare Professional or Researcher

APPLICANT INFORMATION

SUBMIT COMPLETED APPLICATION BY: