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Full Name: *

Use your real name here. You can specify an alias later.

Member Alias

If you would like to be called something other than your name, list it here.

Age *

Knowing your age helps us make appropriate matches.

Birthdate

This is optional. However, if you share your birthday, you can receive a birthday card.

Contact Info

Phone/TTY *

We need this in order to verify your enrollment. If you do not have a phone number, contact us.

Email *

Your email address is private and will not be shared with anyone.

Mailing Address *

A valid address where you receive mail

Address 2

City *

State *

Zip *

Country

Special Days

I celebrate (select all which apply) BirthdayThanksgivingJewish HolidaysNew Years (Dec.31-Jan1)New Years (Chinese, Lunar)KwanzaaChristmas

Other holidays, et c.

Enter other special dates here, seperated by commas

Diagnosis

My official diagnosis includes * Cervical DystoniaBlepharospasmOromandibular dystonia (cranial dystonia)Laryngeal dystonia (spasmodic dysphonia)Hand dystonia (writer’s cramp)MultifocalEarly-onset generalizedPsychogenic dystoniaDopa-responsive dystoniaMyoclonic dystoniaParoxysmal dystonias and dyskinesiasparkinsonism

I use the following adaptive equipment *

Helps us match you...

Other instructions/preferences

I agree not to share information about other participants. *

I agree not to transmit anything hurtful, demeaning or bigoted while a member of the Dystoniacs. *

I understand that participation in this program means I will send and receive traditional mail to/from another member if/when I am matched to a pen-pal. I want to participate and intend to send at least one letter/card/package to my pen-pal every 90 days. I understand If I am not able to do this, I should inform ptDystoniacs asap. *

In addition to adding my name to Dystoniacs' Club, include me when you send a periodic email. *

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