Families of
Spinal Muscular Atrophy
Canada

Print-and-Mail Membership Form

P.O. Box 97        Rivers, Manitoba R0K 1X0        (800) 866-0016

When you join FSMA Canada, you will receive all the benefits of joining FSMA-US, including the newsletters Directions and Compass. You will also receive our newsletter, Northern Directions, and be added to the our e-list for SMA research news. You will be giving and receiving support to other families in Canada and around the world, and helping to find a cure for SMA.

To join Families of SMA Canada, print this form, fill it out, and mail it to us with your donation. Make cheques payable to "Families of SMA Canada."

Families of SMA Canada, P.O. Box 97, Rivers, Manitoba R0K 1X0

Name: __________________________________________
E-mail address: __________________________________________
Street Address: __________________________________________
City: __________________________________________
Province: __________________________________________
Postal Code: _______________ Country: Canada
Business phone: _______________ Home phone: ______________
I am/have/had a family member or friend affected with —
SMA Type: [ ] I (Werdnig-Hoffmann Disease) [ ] II (Chronic)
[ ] III (Kugelberg-Welander Disease) [ ] IV (Adult Onset)
[ ] Adult Onset X-Linked (Kennedy's Syndrome) [ ] Don't know
Name: __________________ Sex: [ ] M    [ ] F
Birth date: __________________ Diagnosis date: __________________
Father's name: __________________ Mother's name: __________________
Current status: __________________ Relationship: __________________
Date of death :
(if applicable)		 __________________
If you have additional family members diagnosed with SMA, please provide the same
information for each one on an attached sheet of paper.
We ask for a yearly donation for membership to help cover costs for printing and mailing of newsletters. Your membership is a tax-receiptable donation. We try to make all our materials available based on need, never ability to pay. If you cannot afford a membership donation at this time but would still like to be a member, please check off 'Membership Scholarship.' Scholarships are available only to Canadian residents.
I am including my annual membership donation, as follows —
[ ] Family/Affected/Friend
Cdn$30		 [ ] Professional
Cdn $35		 International (outside Canada) please join FSMA-US

This is a:  

  [  ] Renewal  [  ] Membership
Scholarship needed
    [  ] New membership 
Have you received your initial information packet?   [ ] Yes   [ ] No
I'm enclosing an additional contribution of $
[ ] I authorize Families of SMA Canada to release my name, address, and phone number to other SMA families.
[ ] I authorize Families of SMA Canada to release my name and address to researchers investigating SMA.
Office use —
IS __________________ Date __________________

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