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FRANCAIS    

Become a member of Families of SMA Canada

Membership entitles you to receive our newsletters, updates on research and events in your area. You also can become connected to other families and individuals affected by SMA. To become a member, please fill out this online form for submission electronically - or print it out the downloadable membership form and mail or fax it to us at the head office. Fax to 604-824-1363 / Mail to Families of SMA Canada 103-7134 Vedder Rd. Chilliwack, BC V2R 4G4

We ask for a donation of $30/year per family to help cover printing, mailing and administrative costs. Instructions for making a donation will show after you click 'Submit.'

Name of person completing this form
Family Name
E-Mail
Family Address
City, Prov, Postal Code
Home Phone
Work Phone
Mobile Phone
Mother/Wife/Guardian
Address if not the same as above
Phone if not the same as above
Father/Husband/Guardian
Address if not the same as above
Phone if not the same as above
Your relationship to affected person
Affected person's name
Male/Female?
Date of birth
SMA Type (1, 2, 3, 4, or unknown)
Date of diagnosis
Current Status
Date of death (if applicable)
May we add your name to our family contact list? (yes/no)
How did you hear about us?
(Internet, Facebook, Word of Mouth, Hospital recommendation, etc)

Please list unaffected family members
(siblings, children, parents)
Please use the format below, 1 per line.
Name - Sex - Year of birth - Relationship

Please prove you are human in the usual way.
The CAPTCHA form is not case-sensitive - you can use all little letters.