01. People living with MSA

Please find below our registration form for people living with MSA.

Once we have received your form we will send you a membership pack. You will also automatically receive our MSA News magazine three times a year and any local Support Group invitations. If you would like any support filling out the form, or have any other questions that you would like help with, please contact the office.
Name:*
Title: First: Surname: Preferred name:
Address:*
Street Address Address Line 2 City County Post Code Country
Email:*

If you live outside of the UK or Ireland we will automatically send all correspondence to you via email.
Phone:*
Additional Phone number:
If you are completing this form on behalf of a person living with MSA, tick this box to confirm you have spoken to them and they have consented to you completing this form.
- Yes, I have their consent

Date of Birth:*
Day
Month
Year
NHS Number or HSE Number (Republic of Ireland):
Diagnosis:*
- MSA-P
- MSA-C
- MSA
Date of Diagnosis:*
Day
Month
Year
Pre-MSA Diagnosis (if applicable):
Date early symptoms first appeared:*
Day
Month
Year

Name of Main Carer:
First Last
If you provide details for your main Family Carer, we will also register them as a member:
What is the Carers relationship to you?
Carers email address:
Carer Contact Details if Different from Above:
Please check the following box if you have your carers permission to sign them up for the same e-mail contact from the MSA Trust as yourself (e.g. Support Group invitations and MSA News)
- Yes, my carer wishes to receive contact from the MSA Trust by e-mail
Please tick here if you live alone and have no permanent carer:
- I have no permanent carer

If you live in the UK or Ireland have you already spoken to, or been in contact with, one of our MSA Health Care Specialists?:*
- Yes
- No
If not, are you happy for them to make contact with you?:
- Yes
If you live in the UK or Ireland have you already spoken to, or been in contact with, our Social Welfare Specialist?:*
- Yes
- No
If not, are you happy for them to make contact with you?:
- Yes
Would you like to receive invites to any MSA Support Groups that might be running in your area? (please note we run Support Groups digitally for people living in the UK and Ireland and In-person in some areas):*
- Yes
- No

Contact Consent
Please tick the boxes below to let us know how you are happy to be contacted by our support staff e.g. MSA Health Care Specialists. We will send you a membership pack by post, however, please tick the boxes below to let us know how we can contact you in the future:*
- Email
- Telephone
- Post
- No contact
You can change your mind or withdraw your consent at any time in the future by telling us.
Are you happy to receive specific fundraising communications:*
- Yes
- No
NCARDRS - If you live in England we can share identifiable information with the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS). This will only take place if you give us explicit permission to do this. NCARDRS is part of NHS England and collects data to get a better understanding of rare diseases and improve services and treatment through research and evaluation. The data collected includes your name, address, date of birth, NHS number, diagnosis and who your doctor and consultant are. If you live in England, do you give permission for the MSA Trust to share your identifiable data with NCARDRS?:
- Yes
- No
You can find out more information about NCARDRS - here
By only consenting to telephone contact the Trust will be unable to send you any information including Support Group invitations or the MSA News magazine. If you’re happy with this please continue completing the form.
General Data Protection Regulation (GDPR): Information you supply will be used to provide and improve our services to you. We promise to respect any personal data you share with us, keep it safe and not do anything with it that you wouldn’t reasonably expect. We will only ever pass on your information to external agencies that are working for us to provide support or services. These agencies hold specific data contracts with us, are also bound by data protection legislation and will destroy all information held on completion. We never pass on your information to external sources for fundraising purposes. To find out how we use your data, view our privacy statement - www.msatrust.org.uk/policy-statements/ , email support@msatrust.org.uk or contact us on 0333 323 4591.
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If you live in the UK or Ireland please provide us with details of your GP and specialist, we will then write to them with information about MSA.

Contact Consent