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Your information

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First Name *
Last Name *
Email *
Re-type email *
Phone Number *
Address 1 *
Address 2
Town *
County *
Post Code *

Details of the person with arthrogryposis

Person with AMC is.... *
Date of birth of person with AMC *         
Which limbs/muscles are affected by AMC *

How does AMC affect your daily life? (tick one) *

Needs little or occasional help
Needs regular help or assistance
Needs constant help or assistance
Please give the name of any clinic and/or hospital you/they may attend: *

What are you looking for from TAG (tick all that apply) *

Information on AMC
Help and Advice for Babies & Children
Other Medical Help
Meet people with AMC
Speak to people with AMC
Other (Please give details)

Additional Information

The Arthrogryposis Group (TAG) will only use your personal information to provide you with information, services or products you have requested, for administration purposes and to further our charitable aims. By completing this form you are giving permission to share the information contained within it with others involved with TAG.

If you do not wish to share your information with others in TAG please tick this box

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