Duchenne Muscular Dystrophy Rare360 Perspectives, Insights & Experiences (P.I.E)
Subscribe to the DMD Rare360 P.I.E. program! This free program hosted by the Rare Advocacy Movement and Rare Love, is designed to connect you to fair market value earning opportunities in your region for your rare disease-specific lived-experiences. Have questions? Email us at info@rareloveventures.com.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
Please enter a valid phone number.
Choose all of the following options that best describe you:
*
I am a person diagnosed with Duchenne Muscular Dystrophy
I care for someone diagnosed with Duchenne Muscular Dystrophy
I care for someone suspected to have Duchenne Muscular Dystrophy
I have another rare disease diagnosis other than Duchenne Muscular Dystrophy
I am a friend and ally to the Duchenne Muscular Dystrophy Community
None of the above
My age is
*
13-16
17-25
26-35
36-45
46-55
56-65
65+
Prefer not to say
I identify as ____________ [select all that apply]
*
White Person
Black Person
Brown Person
Hispanic/Latin Person
Person of Color
Mixed Person
Bi-racial Person
Multi-racial Person
Human
Other
I identify as ____________ [select all that apply]
*
African
African American
Alaska Native
American Indian
Native Hawaiian and Pacific Islander (Carolinian, Chamorro, Chuukese, Fijian, Guamanian, Hawaiian, Kosraean, Marshallesse, Native Hawaiian, Niuean, Palauan, Pohnpeian, Papua New Guinean, Samoan, Tokelauan, Tongan, Yapese)
Central Asian (Afghani, Armenian, Azerbaijani, Georgians, Kazakh, Kyrgyz, Mongolian, Tajik, Turkmen, Uzbek)
East Asian (Chinese, Japanese, Korean, Okinawan, Taiwanese, Tibetan)
South Asian (Bangladeshi, Bhutanese, Indian, Maldivians, Nepali, Pakistani, Sri Lankan)
Southeast Asian (Bruneian, Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Timorese, Thai, Vietnamese)
Middle Eastern (Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, Turkey (straddles Europe and Asia) United Arab Emirates and Yemen)
European (Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Kazakhstan, Kosovo, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Moldova, Monaco, Montenegro, Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Russia, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, UK, Vatican City (Holy See))
White American (unknown ancestry)
Central American (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama)
South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Peru, Suriname, Uruguay, Venezuela)
Caribbean (Cuba, Dominican Republic, Haiti, Guadeloupe, Martinique, Puerto Rico, Saint-Barthelemy, Saint-Martin)
Hispanic / Latino (unknown ancestry)
Bi-racial
Multi-racial
Other
Prefer not to say
I identify my gender as
*
Male
Female
Non-binary
Cis-gender
Third gender
Transgender - Transgender is an umbrella term that refers to people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth. Other identities considered to fall under this umbrella can include non-binary, gender fluid, and genderqueer – as well as many more. (Credited to the Human Rights Campaign)
Prefer not to say
Rare360 P.I.E programs are hosted by the Rare Advocacy Movement (RAM) and Rare Love. RAM is dedicated to preserving your data privacy rights and as a result, this form is secured under a HIPPA compliant server and GDPR abiding policies. By joining this list of subscribers, you consent for RAM to email you regarding market research and/or advocacy opportunities that you may qualify for.
*
I consent to subscribe to the Duchenne Muscular Dystrophy Rare360 P.I.E. Mailing List.
Submit
Should be Empty: