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Patient/Parent Registration

Welcome to Cure JM! By registering as a Patient and/or Parent, you will receive a Welcome Kit, brochure, information cards and Cure JM awareness wristbands. You will also receive the latest e-news from Cure JM, including information about events in your area. You will also have the opportunity to join the (optional) Family Support Network, where you can be connected to other families affected by this disease. At the same time, you will be actively engaging in the movement to find therapies and a cure for Juvenile Dermatomyositis and Juvenile Polymyositis. Your information will be DE-IDENTIFIED, meaning your name will never be disclosed to researchers WITHOUT YOUR PRIOR CONSENT. The only information provided to researchers would be demographic information and patient data, without any direct identifiers, such as your name. This data is absolutely essential to advance JM research. Both patients and parents hold the key to unlocking solutions---your information, your history, and your help can provide the answers toward a cure for JM!

Thank you for joining the fight for a cure.

If you have any questions or any problems with the registration process, please contact .

PLEASE COMPLETE ALL FIELDS

Contact Information (Parent/Guardian or Patient if patient is an adult)

 
First Name:
Last Name:
Street Address:
City:
State/Province:

If you selected "Other" please elaborate here:

Zip/Postal Code:
Country:
Cell Phone:
eMail:
eMail Verification:
Alternate eMail:
Relationship to Patient:

If Parent/Guardian is selected, please enter below information for the other parent/guardian (if applicable):

Parent #2 First Name:
Parent #2 Last Name:
Parent #2 eMail:

Patient Information

First Name:
Last Name:
Click here if Patient Address is the same as above.
Street Address:
City:
State/Province:

If you selected "Other" please elaborate here:

Zip/Postal Code:
Country:
Cell Phone:
eMail:
Sex of Patient:
Date of Birth:
         

Type of Myositis:


If "Other" please describe:


Diagnosis Information

Date of Diagnosis:
         
In Remission?
Length of Time between first symptoms and diagnosis: months
Treating Doctor:
Treating Hospital:
Other Health Issues?

Where (geographically) did symptoms first appear?

City:
State/Province:

If you selected "Other" please elaborate here:

Country:

Welcome KitCure JM Foundation Welcome Kit
Would you like us to send you a free copy of our Welcome Kit?


Join the Cure JM Family Support Network
The Family Support Network was created to give both JM sufferers and parents of children affected by JM the ability to connect and share experiences, questions and concerns. Would you like to join?


Join Team JM
Team JM is seeking members who would like to help us raise public awareness of JM, facilitate fundraising efforts, and spread the word about Cure JM. There's no cost to join Team JM, the only thing we require is a passion and desire to eliminate this disease. Would you like to join?


How did you hear about us?
If "Other" please elaborate:


Grandparents CARE Support Network
Cure JM also supports grandparents of patients diagnosed with JM. Grandparents also receive a Welcome Kit, awareness wristbands, our monthly e-newsletter, and invitations upcoming events in your area. Most of our Cure JM grandparents find it extremely helpful to connect with other grandparents of JM children.

Grandparent #1

First Name:
Last Name:
eMail:
Street Address:
City:
State/Province:

If you selected "Other" please elaborate here:

Zip/Postal Code:
Country:

Grandparent #2

First Name:
Last Name:
eMail:
Street Address:
City:
State/Province:

If you selected "Other" please elaborate here:

Zip/Postal Code:
Country:

Grandparent #3

First Name:
Last Name:
eMail:
Street Address:
City:
State/Province:

If you selected "Other" please elaborate here:

Zip/Postal Code:
Country:

Grandparent #4

First Name:
Last Name:
eMail:
Street Address:
City:
State/Province:

If you selected "Other" please elaborate here:

Zip/Postal Code:
Country:

Any comments or questions?



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