Membership Form

Are you*

A person living with a neuromuscular conditionA family member / partner of someone living with a neuromuscular conditionOther
What is your reason for contacting Neuromuscular WA today?

Myself or someone in my family has a neuromuscular condition and we'd like to access Neuromuscular WA's servicesTo become an Ordinary Member (I don't need to access services)
What services are you interested in?*

System NavigationEvents & ProgramsGeneral AdviceEmpower FundCounsellingUnsure
Please tell us who you are.*

First NameLast Name
What is your diagnosis, or suspected diagnosis if you are yet to be diagnosed?
What is your sex assigned at birth?*

MaleFemaleIntersex
What is your gender identity?
Please type below your gender identity.
What are your preferred pronouns?

She/Her/HersHe/Him/HisThey/Them/TheirsNo PreferenceNot Listed
What is your best contact number?*
Please enter a valid phone number.Format: 0000 000 000.
What is your email address?
example@example.com
What is your preferred method of contact?*

Phone callEmailText message
What is your date of birth?*

DayMonthYear
Date
What is your address?*

Street Address

Street Address Line 2

SuburbState

Post Code
Would you like to add any of your family as members with you? This will allow them to attend events with you, and access our services and supports.*

YesNo
How many people in addition to yourself, would you like to register as members?*
I would like to add:   First Name*   Last Name*
My relationship with them is: *
Does this person have a neuromuscular condition?Yes   No*
What is their date of birth?   Date of birth*
Please share their contact details if different from your own:    Type a label
The second person I would like to add:   First Name*   Last Name*
My relationship with them is: *
Does this person have a neuromuscular condition?Yes   No*
What is their date of birth?   Date of birth*
Please share their contact details if different from your own:    Type a label
The third person I would like to add:   First Name*   Last Name*
My relationship with them is: *
Does this person have a neuromuscular condition?Yes   No*
What is their date of birth?   Date of birth*
Please share their contact details if different from your own:   Type a label
The fourth person I would like to add:   First Name*   Last Name*
My relationship with them is: *
Does this person have a neuromuscular condition?Yes   No*
What is their date of birth?   Date of birth*
Please share their contact details if different from your own:    Type a label
The fifth person I would like to add:   First Name*   Last Name*
My relationship with them is: *
Does this person have a neuromuscular condition?Yes   No*
What is their date of birth?   Date of birth*
Please share their contact details if different from your own:    Type a label
How did you find out about us?*

Current or previous memberFamily member or friendMedical professional or allied health workerNeuromuscular WA websiteGoogle or search engineNeuromuscular WA social mediaOther
Please tell us why you are contacting Neuromuscular WA. *
Thank you for your membership application. Details of the services you can access with your membership can be found at Neuromuscular WA's website. If you have any questions about these please contact us on 9380 3400.

As this document collects personal information, please read our Privacy Policy to understand how we will use and store this information.

We'll be in touch soon!
What is your connection to neuromuscular conditions? Why would you like to become a member of Neuromuscular WA?*
Thank you for reaching out to Neuromuscular WA. Our team will respond to your enquiry shortly.

As this document collects personal information, please read our Privacy Policy to understand how we will use and store this information.
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