Join HMDSN

It would be nice if you could enter the following information. As this groups involves supporting children, we do ask for information that will clearly identify yourself. This is in order to keep everyone as safe as possible. This will also give us some idea of the reason that you want to join the group so that we maybe able to help you better.

All information is held in the strictest confidence and will never be passed onto any 3rd party or disclosed to other members of the group.

All items marked with an "*" must be input

Please pick which category you fall into and therefore which group you wish to join;* Parent with a Child having problems Adult with problems
Your Surname: *		First Name: *
Child´s Name: *		Child's Date of Birth: *
Email Address: *		Day Month Year

Address:
First Line: *		Second Line:
Third Line:		Town/City: *
County/State: *		Post/Zip Code: *
if "county/state" or "Post/Zip Code" are not applicable then input "n/a"		Country *

The Main Hospital that you/your child was treated at?: *
What Type of Motility problem does your child have? *
If Hirschsprung's (HD) is the problem, which type?

Describe What Type of HD or other Motility Problem: *	Any other relevant Information?:

I have read & understand the terms & conditions as defined out in the preceding 2 pages and agree to abide by them
To help us improve getting the message out could you please tell us where you heard about us?