DYNA Membership Application

***IMPORTANT NOTE:
All information must be complete for registration to fully process. Please do not leave blank spaces.
Data will be entered into our system exactly as you type it so please be accurate. Use proper capitalization with your names etc. or you will have to reapply.
Parents of teens should supervise their teens with the application process but should not apply for them. DYNA is an organization dedicated to serving youth who wish to become involved with dysautonomia support and awareness, therefore the teens who apply for membership need to have the interest to join.

If your child is 13 and under you must submit consent, as stated on the previous page, prior to filing out this application. Contact us if you have any questions.

To apply for DYNA membership, make sure you have fully reviewed the member information on the proceeding page. If you meet the criteria, please fill out the form below and push the submit button when you are finished.

If you are a physician or medical personnel interested in our organization, please email us directly at: info@dynakids.org.

Required Field *
Please Select What Type of Member You are *

New Current Other

First Name *

Last Name *

My Date of Birth* ex: 01/31/2000

My Age*

My E-Mail Address * (please double check your email address and confirm that you entered it correctly)

My IM Screen Name

Specify if AOL or Yahoo, etc.

Parent's (or Spouse) Name(s)

Parent's E-Mail Address(es) (if under 21)

My Home Mailing Address *

City *	State *	Zip Code *

Country

Please list a daytime phone number where you can be reached during normal office hours EST.

Daytime Number * ex: 301-555-1212

Optional Number (cell phone etc)

Dysautonomia Doctor's Name

Doctor's Mailing Address (for newsletter mailing list)

City		State		Zip Code

Sibling's (or children's) Name(s)		Age

How did you hear of our site?*

Our Internet Clubs will use the following information to list in your profile:

My Name*

My Age*

The state I live in*

The Dysautonomia condition I was diagnosed with*
(no other medical conditions will be listed in your profile)

The hobbies or things I enjoy doing *
(don't write a book - we don't have room for much!)

After you push submit, please click on the link for the Consent Form.