• Current Person with MND
  • Main informal carer
  • Details
  • Children and Young People support
  • Support Volunteers
  • Confirmation
  • MND Association Details
  • Complete

Please note:

The completion and submission of this form confirms that the person with MND has consented to the MND Association keeping a record of their details which will be stored securely in accordance with the requirements of Data Protection Regulations.

Person with MND

The following sections are optional and can be left blank if you prefer not to answer: Date of birth, Gender, Ethnicity, Sexual Orientation, Religion.

There is no obligation to provide this information but it is used anonymously and is invaluable in helping us determine to what extent different communities are and are not using our services and most importantly to then identify and remove barriers to participation. We are committed to becoming a fully inclusive organisation.

    Name
    Title
    Click here to enter your address manually.
    Preferred method of contact
    If known.

    Main informal carer

    The person that provides/would provide non-paid care and support on a regular basis (For example, Spouse, Partner, Parent, Family member/Friend)

      Name
      Title
      If applicable.
      Main informal carer address
      Preferred method of contact
      Relationship to person with MND

      Details

      GP details

      GP Surgery Address

      Neurologist details

      Neurologist address

      Referrer details

      Name of referrer
      Click here to enter your address manually.

      Additional information

      Please use this space to advise of any other relevant information that will assist us with supporting the person with MND. (e.g. speech difficulties, English not first language)

      Children and Young People support

      Children and Young People aged 18 and under (or up to 21 where the child or young person has additional needs). We offer a wide range of support for children and young persons who are affected by MND.

        Would the person with MND like information about Children and Young People services?

        Please detail below the name and date of birth of each child or young person requiring support - this is so age-appropriate information and support is provided.

          Support Volunteers

          The Association has a network of Support Volunteers who perform a vital role in supporting people affected by motor neurone disease – both those living with the disease and those close to them. All are volunteers who have been carefully selected and have undergone a thorough training programme. The Support Volunteers are based in the local community as members of a team and can offer support virtually, over the phone or via e-mail, or will visit them in their own home.

          We also have a network of Branches and Groups and some offer support via meetings.
          Please note that we do not have visitors available in every area of England, Wales and NI, however we can offer on-going support and help through regular contact with MND Connect (our Helpline) and in other ways if required.

            Please tick the relevant boxes below:

            Confirmation

            MND Association Details

            Section 1

            We would like to know what information you are interested in receiving and how you would like us to contact you in the future. You can change your mind at any time.

            Sharing information with local health and social care professionals and Association Support Volunteers

            Person with MND's information choices

            Our services
            Would you like the Association to keep you updated on the services it provides and funds? This could include local newsletters on activities taking place in your area.
            Updates
            Would you like the Association to send you updates on the work being done locally and nationally including ways to get involved or help? These updates could include information about volunteering, campaigning or in supporting the Association financially.
            Association membership
            Would you like to become a member of the Association and receive a welcome pack and the quarterly magazine Thumb Print? Note: We provide support to people affected by MND regardless of whether they are a member or not.
            Communication preferences
            We greatly appreciate your support and would like to keep in contact with you about our news, fundraising activities and appeals. To see how we use your data please read our Privacy Policy. Please select all the ways you would like to be contacted below.

            Main informal carer information choices

            Our services
            Would you like the Association to keep you updated on the services it provides and funds? This could include local newsletters on activities taking place in your area.
            Updates
            Would you like the Association to send you updates on the work being done locally and nationally including ways to get involved or help? These updates could include information about volunteering, campaigning or in supporting the Association financially.
            Association membership
            Would you like to become a member of the Association and receive a welcome pack and the quarterly magazine Thumb Print? Note: We provide support to people affected by MND regardless of whether they are a member or not.
            Communication preferences
            Please see our privacy policy for full details on how we use your information. Would you like to receive regular updates on the work we are doing, including details of ways in which you, your friends and family could help? These updates could include information about volunteering opportunities, ways of helping in our campaigning activities or in supporting the Association financially. Please select how you are happy to receive these communications:

            You can stop receiving information or change your consent(s) at any time. Email [email protected] or call 0808 802 6262.