NYA Membership Application

Please fill out this form and click "send".
(* indicates required fields)

First Name *

Middle Initial

Last Name *

Nickname

Address Line 1: *

Address Line 2:

City/Town: *

Country *

State *

Zip *

Home Phone *

Cell Phone

Current Age *

Birth date (MM/DD/YYYY) *

HD Relationship

At-Risk
Positive
Negative
Relative/Friend With HD

How do you want to receive HDSA notices on NYA activities

Email
Mail
Both

Email: *

Alternate Email

Personal Website (only if you want to share)

IM's You Want To Share

In Case of An Emergency

Provide the person or physician to be contacted in an emergency.

First Name *

Middle Initial

Last Name *

Relationship to you *

Address Line 1: *

Address Line 2:

City/Town: *

Country *

State *

Zip *

Home Phone *

Cell Phone

Email Address *

Tell Us About Your Membership in a HDSA Chapter or HD Support Group

Do you currently belong to an HDSA Chapter?

Yes
No

If yes, what is the name of the Chapter?

Your Support to the NYA

Please write your thoughts on what you feel the NYA's primary goal(s) or purpose should be

If asked, how do you feel you could best support the NYA?

Fund Raising

Letter Writing

Emotional Support

Silent Auction Items

Media Attention

Education/Awareness

Other

Level of support you can provide (time)

Best time to contact you

Time zone (please indicate EST, CST, MST, etc.):

If you have any questions about the NYA please ask them here:

HDSA NYA Application - Optional Information

Permission to Use: In order to help the other members on the NYA get to know you better, portions of the information you provide below may be used when you are "introduced" to the NYA Yahoo Message Board by a group by email.

Do we have your permission to share this information?

Yes
No

You and HD

: If you're answer is no, the below information will not be shared but will be used to help the HDSA develop specific programs or educational material for young people living with HD.

Tell Us About You and HD

Who in your family has HD? How has living with HD affected you? What are some things you would like to know from other NYA members about HD, etc.

Tell Us A Little Bit About You!

Are you in school? What grade are you in? What type of work you do? How many sisters and brothers do you have? What is your favorite website, music, things to do, etc.

Tell Us About Your Favorite Hobbies!

Are there any hobbies you enjoy, talents you may have or groups you're a member of, etc.?