PatientCrossroads CMD


           
Registration

Welcome to the Congenital Muscle Disease International Registry (CMDIR)

Thank you for taking the time to complete your profile and assisting the effort in finding a treatment and cure for these diseases. 

Please note, if there is more than one affected individual in your family, you may use the same login and password to create multiple profiles. However, a separate survey must be completed for each family member.  This can be done after registering by clicking "Add a Family Member" from your profile page.

Please click here to read the Consent to Participate in the CMDIR prior to registration.  
If you have any questions, please contact us at:  This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Registrant First Name: * This Field is required
Registrant Last Name: * This Field is required
Relation to Patient: * This Field is required Information for: Relation to Patient : <p>
	Please tell us how you are related to the patient.</p>
E-mail: * This Field is required Information for: Email : Please enter a valid e-mail address. A confirmation email will be sent to this address upon registration.
Username: * This Field is required Information for: Username : Please enter a valid username.  No spaces, at least 3 characters and contain 0-9,a-z,A-Z
Password / Re-enter password: * This Field is required Information for: Password : Please enter a valid password.  No spaces, at least 6 characters and contain lower and upper-case letters, numbers and special signs * This Field is required Information for: Verify Password : Please enter a valid password.  No spaces, at least 6 characters and contain lower and upper-case letters, numbers and special signs


This page does not complete your registration!

Upon completion of this page, please continue entering information
about the affected individual.  


* This Field is required I consent to participate and share de-identified information with the CMD GaP study at NCBI.
* This Field is required I consent to participate and share limited identifying information with the CMD BioBank if I or my child donates a specimen.
* This Field is required I consent to participate and share limited identifying information with the CMD Tissue Repository if I or my child donates a specimen.

Please specify one of the following:



* This Field is required I have read and understand the consent and agree to participate in the registry.

Assent: I am a person with congenital muscle disease between the ages of 8 and 17 years. The purpose of the CMDIR and how my data will be stored has been explained to me. My parents and I have discussed any further questions I may have with the CMDIR Counselor. Participation in the CMDIR has been explained to me and I agree to participate. I will be contacted when I turn 18 years of age and will be asked to consent as an adult.

* This Field is required Please indicate your assent to participate as the affected individual between ages 8-17

Please enter the code below to complete your registration:
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