Muscular Dystrophy Ireland

Membership Application Form

General Details
Name / Date
Address
Telephone Numbers / Home / Mobile / Work
From time to time MDI would like to send you text messages about fundraising, social and other events which you may be interested in. If you would like to receive these text messages please tick this box:
Email
Type of Membership & Annual Subscription Rates
Please tick whichever of the following applies to you
Person with MD Family Membership Friend of MDI
€15.00 €20.00 €15.00
If you would like to make a donation additional to the membership fee,
please indicate the amount here: / €
Total amount enclosed with this form: / €
Would you like a receipt? / Yes No
MDI Database
To enable us to update our records and maintain accurate information, we would appreciate it if you would provide the following information regarding your family if applicable:
Note: When specifying “Type of MD” please see list overleaf and tick appropriate. Thank you.
Name(s) of Person(s) with MD / Date(s) of Birth / Type of MD
All cheques and postal orders should be made payable to Muscular Dystrophy Ireland.
It is also possible to pay your subscription by Standing Order to our account;
Muscular Dystrophy Ireland Savings Account at Bank of Ireland, 2 College Green, Dublin 2. BIC: BOFIIE2D IBAN: IE11BOFI90001775261619
Please complete this form and return it, with the relevant membership fee (see above) to:
Muscular Dystrophy Ireland, 75 Lucan Road, Chapelizod, Dublin 20. Thank You.
Types of Muscular Dystrophy
Each year MDI organises Information Days on specific types of muscular dystrophy. If you have a form of muscular dystrophy, we would be grateful if you could specify the exact type by ticking the appropriate box below. This will insure that you are invited to appropriate MDI Information Days and provided with relevant available updates and news on research and treatments for your specific condition. The conditions listed below are covered by MDI. For more information on a specific condition, visit: http://www.mdi.ie/types-of-muscular-dystrophy.html. If you are in any doubt over whether MDI covers the condition you or someone you know has, please do not hesitate to contact our Information Officer by emailing or phoning (01) 6236414.
Please tick appropriate box which applies to you or your family member(s):
1. Muscular Dystrophies
Becker muscular dystrophy / Facioscapulohumeral muscular dystrophy
Duchenne muscular dystrophy / Limb-girdle types of muscular dystrophy (LGMD) - General
Manifesting carrier of Duchenne / ·  LGMD 1B (also known as Laminopathy)
Congenital muscular dystrophy - General / ·  LGMD 1C (also known as Caveolinopathy)
·  MDC1A (merosin-deficient congenital muscular dystrophy) / ·  LGMD 2A (also known as Calpainopathy)
·  Rigid spine syndrome (RSS) / ·  LGMD 2B (also known as Dysferlinopathy)
·  Ullrich congenital muscular dystrophies / ·  LGMD 2I
·  Bethlem myopathy / Ocular myopathies including ocularopharangeal muscular dystrophy
Emery-Dreifuss muscular dystrophy
2. Myotonic Disorders
Congenital Myotonic Dystrophy
Myotonia
Myotonic Dystrophy
3. Congenital Myopathies
Central Core Myopathy
Congenital fibre-type disproportion myopathy
Minicore (Multicore) myopathy
Myotubular or Centronuclear myopathy
Nemaline myopathy
4. Mitochondrial Myopathies
5. Metabolic Disorders
Metabolic disorders (general)
McArdle’s Disease
Pompe’s Disease
6. Periodic Paralyses
7. Autoimmune Myositides
Polymyositis, Dermatomyositis and Sarcoid myopathy
Juvenile dermatomyositis
Inclusion body myositis
8. Spinal Muscular Atrophies
Severe (Type I)
Intermediate (Type II)
Mild (Type III)
Adult spinal muscular atrophy
9. Hereditary Motor and Sensory Neuropathies
(Also known as Charcot-Marie-Tooth or Peroneal muscular atrophy)
10. Disorders of the Neuromuscular Junction
Congenital myasthenic syndromes
Myasthenia Gravis
11. Friedreich’s Ataxia
12. Other (Please Specify)