National Fibromyalgia Association: Survey - Support Group Registration Form

Support Group Registration Form

Thank you for registering a new fibromyalgia support group in your local area. You are your way to making a huge impact in many people's lives that are affected by this disorder. Please information below. When you are finished, the information will be reviewed and approved for listing on our website.

Question - Not Required - Support Group Name

(Maximum response 255 chars, approx. 5 rows of text)

Please fill out the following Support Group Leader contact information.

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Name:

First Required	Last Required

*

Email: Required

Phone Number:

Remember me. What's this?

Question - Not Required - Co-leader/Alternative Contact Name

Question - Not Required - Co-leader/Alternative Contact Phone Number

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Co-leader/Alternative Contact Email Address

*

Question - Required - Support Group Mailing Address

*

Question - Required - City

*

Question - Required - State

*

Question - Required - Zipcode

Question - Not Required - Support Group Website

Question - Not Required - Support Group Purpose

(Maximum response 255 chars, approx. 5 rows of text)

Support Group Meeting Location


	Street 1:
	Street 2:
	City:
	State / Province:
	ZIP / Postal Code:
	Country:
	If you respond and have not already registered, you will receive periodic updates and communications from National Fibromyalgia Association.

*

Question - Required - Meeting Day(s)

*

Question - Required - Start time

Question - Not Required - End time

Question - Not Required - Membership cost/donations

Question - Not Required - Activities

(Maximum response 255 chars, approx. 5 rows of text)

Terms and Conditions for NFA Support Group Directory

As the support group leader, I understand that All my information posted is available publically, and I accept all responsibility for my group’s listing in the NFA Support Group Directory and will ensure that the information is updated and accurate.

I will also ensure that all information, documents, pictures, notices and links posted on our support group directory page do not contain obscene or offensive language or images and do not give medical advice.

I understand that our directory page can not be used for financial gain, the selling of goods and services, or be linked to commercial websites.

I understand that the Support Group Directory is designed to assist patients and their caregivers in finding a local support group and also serves as a way to share information with group members.

The NFA reserves the right to remove any content that we deem unsuitable for the Support Group Directory or violates the above

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Question - Required - Yes, I agree to the terms and conditions for posting my support group on www.fmaware.org and understand that violation of these terms could result in having it removed from the National Fibromyalgia Association's Support Group Directory. Yes
No