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Become a member of SRNA, it’s completely free!

Become a member of SRNA and get connected to the information and support you need. Membership includes individuals with these rare disorders, their family members and caregivers, and the medical professionals who treat individuals with these disorders. SRNA currently has more than 15,000 members from more than 111 different countries and has a large number of support groups across the United States and around the world. There are no membership fees.

Benefits include…

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I am a…

Person Diagnosed with a Rare Neuroimmune Disorder

Membership Form

Thank you for signing up to become a member of the SRNA. We anticipate it will take you less than 5 minutes to answer the questions below. Please fill out as much information as possible. Your answers may help us connect you to relevant resources and programs that we offer. The information you provide us will not be made public at any time without your permission. Data we collect may be analyzed as de-identified data and only aggregate results reported and used to learn more about the disease and make reasonable conclusions about the population that may be helpful in designing registries and clinical trials. The SRNA does not share or sell patient data and other confidential information with third parties for any purpose. We respect your privacy. Please view our privacy policy.

Contact Information

First Name Middle Name (Optional) Last Name

What is your date of birth? (providing your date of birth will enable us to connect you to relevant programs. If you do not want to share your full date of birth, please use 01/01 for date and month and provide your year of birth) Preferred Language (Optional)

Race (Optional)

Ethnicity (Optional)

Address Line 1 Address Line 2 (Optional)

CountryUnited States Postal Code City State/Province (Optional)

Email Home Phone (Optional) Mobile Phone (Optional)

Yes, sign me up for email updates.

Remember me so that I can use FastAction next time.

(Optional)

Additional Information

What is your rare neuroimmune diagnosis?

Do you also want to join The Acute Flaccid Myelitis Association?

We have partnered with a mission-aligned organization, The Acute Flaccid Myelitis Association (AFMA) to support, educate, and advocate for those with AFM. You can become a member of the AFMA, subscribe to the AFMA mailing list, and access AFMA programs and support by joining SRNA. The AFMA is a 501(c)(3) registered non-profit association borne from a meeting of parents impacted by AFM. The AFMA is a resource for those that are personally affected by AFM. The AFMA provides shared information based on the experiences of families impacted by AFM. The AFMA also provides grants to patients in need of financial assistance for medical treatment or equipment. Additionally, the AFMA works to increase public awareness to this rising public health issue in an effort to promote advocacy for research. To learn more about the AFMA and their mission, please click here. For more information on privacy policy, data use and how to be removed from database and communication preferences of the AFMA, please click here. You can also contact The AFMA via email or by phone at 916-241-9020. AFMA privacy policy can be found here.

Please check this box if you would like to become a member of The AFMA as confirmation that you give us permission to share membership information that you provide through this form with the AFMA (Optional)
Please check this box if you would like to become a member of The AFMA as confirmation that you give us permission to share membership information that you provide through this form with the AFMA is required.

Yes, my diagnosis is AFM and I would like to become a member of the AFMA

Do you have any of the following conditions? (Select all that apply) (Optional)
Do you have any of the following conditions? (Select all that apply) is required.

Systemic lupus erythematosus or Lupus

Sjogren's Syndrome

Sarcoidosis or Neurosarcoidosis

HIV

Lyme Disease

TSP/HAM - HTLV-1 Associated Myelopathy/Tropical Spastic Paraparesis

None of these conditions

What was the approximate date of your symptom onset?

If applicable, how long did it take from symptom onset to receive a diagnosis? (Optional)

What acute treatments have you received? (Select all that apply)
What acute treatments have you received? (Select all that apply) is required.

IV Steroids

PLEX or plasmapheresis

IVIG

Cytoxan or cyclophosphamide

No treatment has been given

Other

Not sure

What kinds of rehabilitation therapy have you received? (Select all that apply)
What kinds of rehabilitation therapy have you received? (Select all that apply) is required.

Physical therapy

Occupational therapy

Speech therapy

No therapy has been received

If you have received therapy, where did you receive it? (Choose all that apply) (Optional)
If you have received therapy, where did you receive it? (Choose all that apply) is required.

At home

At a general hospital

In a rehabilitation hospital

In an assisted living facility

At an outpatient clinic

Other

If you have received therapy, do you feel you have received adequate rehabilitation therapy? (Optional)

Please select one of the choices below on where you are currently

What symptoms do you currently have? (Select all that apply)
What symptoms do you currently have? (Select all that apply) is required.

Weakness

Paralysis

Numbness

Loss of sensation

Uncomfortable nerve nerve sensations (burning, tingling, etc.)

Spasticity

Bladder incontinence and/or urinary retention

Bowel incontinence and/or constipation

Eye pain

Blurry vision

Double vision

Difficulty with breathing

Fatigue

Sexual dysfunction

Difficulty with speech

Depression

Learning or cognitive issues

Other

Gender

SRNA offers a support network through local support groups and community members located throughout the world. (Optional)
SRNA offers a support network through local support groups and community members located throughout the world. is required.

I would like to be connected to other members or a Support Group Leader

Most of our communications are sent via email, but print versions of newsletters and program announcements are also available. In addition to email, please select the postal mail option if would you like to receive SRNA communications via postal mail (Optional)
Most of our communications are sent via email, but print versions of newsletters and program announcements are also available. In addition to email, please select the postal mail option if would you like to receive SRNA communications via postal mail is required.

Postal mail

Would you like to volunteer for SRNA? (If you select “Volunteer,” we will contact you when there are volunteer opportunities available) (Optional)
Would you like to volunteer for SRNA? (If you select “Volunteer,” we will contact you when there are volunteer opportunities available) is required.

Volunteer

How did you hear about SRNA? (Select all that apply)
How did you hear about SRNA? (Select all that apply) is required.

Internet search

Social media

Medical professional

Another organization

Friend or family member

Other

We at SRNA are committed to bringing support, insight, knowledge, and up-to-date information to our members and providing programs and services to all individuals diagnosed with rare neuroimmune disorders and their loved ones to become empowered advocates for their health.

If you are interested in receiving information & updates about SRNA's programs & services please check the box below. (Optional)
If you are interested in receiving information & updates about SRNA's programs & services please check the box below. is required.

I want to receive information and updates about SRNA's programs and services

Research and clinical studies and trials help us understand more about rare neuroimmune disorders. If you are interested in being contacted about research and clinical trials and studies please check the box below. (Optional)
Research and clinical studies and trials help us understand more about rare neuroimmune disorders. If you are interested in being contacted about research and clinical trials and studies please check the box below. is required.

I want to receive specific information about research and clinical trials and studies

If you are interested in receiving our weekly blog please check the box below. (Optional)
If you are interested in receiving our weekly blog please check the box below. is required.

I want to receive SRNA's weekly blog

If you are interested in receiving pediatric-specific emails please check the box below. (Optional)
If you are interested in receiving pediatric-specific emails please check the box below. is required.

I want to receive pediatric-specific emails

Please note - if you sign up for our Research, Blog, or Pediatric email lists, you will automatically be subscribed to receive emails from SRNA.

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Relative or Caregiver

Membership Form

Thank you for signing up to become a member of SRNA. We anticipate it will take you less than 5 minutes to answer the questions below. Please fill out as much information as possible. Your answers may help us connect you to relevant resources and programs that we offer. The information you provide us will not be made public at any time without your permission. Data we collect may be analyzed as de-identified data and only aggregate results reported and used to learn more about the disease and make reasonable conclusions about the population that may be helpful in designing registries and clinical trials. SRNA does not share or sell patient data and other confidential information with third parties for any purpose. We respect your privacy. Please view our privacy policy.

Contact Information

First Name Middle Name (Optional) Last Name

What is the person diagnosed's date of birth? (providing their date of birth will enable us to connect you to relevant programs. If you do not want to share their full date of birth, please use 01/01 for date and month and provide their year of birth Preferred Language (Optional)

Race (Optional)

Ethnicity (Optional)

Address Line 1 Address Line 2 (Optional)

CountryUnited States Postal Code City State/Province (Optional)

Email Home Phone (Optional) Mobile Phone (Optional)

Yes, sign me up for email updates.

Remember me so that I can use FastAction next time.

(Optional)

Additional Information

What is your relationship to the person with a rare neuroimmune disorder?

What is their name? (Optional)

What is their rare neuroimmune diagnosis?

Is your loved one's diagnosis AFM? Do you also want to join The Acute Flaccid Myelitis Association?

Please check this box if your loved one's diagnosis is AFM and you would like to become a member of The AFMA as confirmation that you give us permission to share membership information that you provide through this form with the AFMA (Optional)
Please check this box if your loved one's diagnosis is AFM and you would like to become a member of The AFMA as confirmation that you give us permission to share membership information that you provide through this form with the AFMA is required.

Yes, my loved one's diagnosis is AFM and I would like to become a member of the AFMA

Do they have any of the following conditions? (Select all that apply) (Optional)
Do they have any of the following conditions? (Select all that apply) is required.

Systemic lupus erythematosus or Lupus

Sjogren's Syndrome

Sarcoidosis or Neurosarcoidosis

HIV

Lyme Disease

TSP/HAM - HTLV-1 Associated Myelopathy/Tropical Spastic Paraparesis

None of these conditions

What was the approximate date of their symptom onset?

If applicable, how long did it take from symptom onset to receive a diagnosis? (Optional)

What acute treatments have they received? (Select all that apply)
What acute treatments have they received? (Select all that apply) is required.

IV Steroids

PLEX or plasmapheresis

IVIG

Cytoxan or cyclophosphamide

No treatment has been given

Other

Not sure

What kinds of rehabilitation therapy have they received? (Select all that apply)
What kinds of rehabilitation therapy have they received? (Select all that apply) is required.

Physical therapy

Occupational therapy

Speech therapy

No therapy has been received

If they have received therapy, where did they receive it? (Choose all that apply) (Optional)
If they have received therapy, where did they receive it? (Choose all that apply) is required.

At home

At a general hospital

In a rehabilitation hospital

In an assisted living facility

At an outpatient clinic

Other

If they have received therapy, do you feel they have received adequate rehabilitation therapy? (Optional)

Please select one of the choices below on where they are currently

What symptoms do they currently have? (Select all that apply)
What symptoms do they currently have? (Select all that apply) is required.

Weakness

Paralysis

Numbness

Loss of sensation

Uncomfortable nerve nerve sensations (burning, tingling, etc.)

Spasticity

Bladder incontinence and/or urinary retention

Bowel incontinence and/or constipation

Eye pain

Blurry vision

Double vision

Difficulty with breathing

Fatigue

Sexual dysfunction

Difficulty with speech

Depression

Learning or cognitive issues

Other

What is their gender?

I would like to be connected to other members or a Support Group Leader

Postal mail

Volunteer

How did you hear about SRNA? (Select all that apply)
How did you hear about SRNA? (Select all that apply) is required.

Internet search

Social media

Medical professional

Another organization

Friend or family member

Other

I would like to be contacted about research and clinical trials and studies

If you are interested in receiving our weekly blog please check the box below. (Optional)
If you are interested in receiving our weekly blog please check the box below. is required.

I am interested in receiving SRNA's weekly blog

I am interested in receiving pediatric-specific emails

Please note - if you sign up for our Research, Blog, or Pediatric email lists, you will automatically be subscribed to receive emails from SRNA.

Your donation will be securely processed.

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Friend, Colleague, or Acquaintance

Membership Form

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Log in or Sign up for FastAction

Contact Information

First Name Middle Name (Optional) Last Name

Preferred Language (Optional)

Race (Optional)

Ethnicity (Optional)

Address Line 1 Address Line 2 (Optional)

CountryUnited States Postal Code City State/Province (Optional)

Email Home Phone (Optional) Mobile Phone (Optional)

Yes, sign me up for email updates.

Remember me so that I can use FastAction next time.

(Optional)

Additional Information

Postal mail

Volunteer

How did you hear about SRNA? (Select all that apply)
How did you hear about SRNA? (Select all that apply) is required.

Internet search

Social media

Medical professional

Another organization

Friend or family member

Other

Clinical studies and trials help us understand more about rare neuroimmune disorders. If you are interested in being contacted about clinical trials and studies please check the box below. (Optional)
Clinical studies and trials help us understand more about rare neuroimmune disorders. If you are interested in being contacted about clinical trials and studies please check the box below. is required.

I would like to be contacted about clinical trials and studies

If you are interested in receiving our weekly blog please check the box below. (Optional)
If you are interested in receiving our weekly blog please check the box below. is required.

I am interested in receiving SRNA's weekly blog

I am interested in receiving pediatric-specific emails

Please note - if you sign up for our Research, Blog, or Pediatric email lists, you will automatically be subscribed to receive emails from the SRNA.

Your donation will be securely processed.

Show your support
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Autofill forms quickly and securely with FastAction

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Medical Professional

Membership Form

Contact Information

First Name Middle Name (Optional) Last Name

Preferred Language (Optional)

Race (Optional)

Ethnicity (Optional)

Home Address Line 1 (Optional) Home Address Line 2 (Optional)

Home CountryUnited States Home Postal Code (Optional) Home City (Optional) Home State/Province (Optional)

Email Home Phone (Optional) Mobile Phone (Optional)

Yes, sign me up for email updates.

Remember me so that I can use FastAction next time.

(Optional)

Employer Information

Role/Title & Department Facility/Organization

I am retired

Work Address Line 1 (Optional) Work Address Line 2 (Optional)

Work Country (Optional)United States Work Zip Code (Optional) Work City (Optional) Work State/Province (Optional)

Work Phone (Optional)

Additional Information

Postal mail

How many patients do you see with rare neuroimmune disorders per month?

Type of Medical Professional
Type of Medical Professional is required.

Clinical Psychologist (PhD)

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

Nurse Practitioner (NP)

Occupational Therapist (OT)

Doctorate of Physical Therapy (DPT)

Orthotist

Physical Therapist

Physician Assistant

Registered Nurse

Surgeon

Social Worker

Other

What is your specialization? (Select all that apply)
What is your specialization? (Select all that apply) is required.

Alternative therapy

Clinical neuropsychology

Emergency Medicine

General Practice/Primary Care

Neurology

Neurosurgery

Orthopedic Surgery

Pain Specialist/Anesthesiology

Pediatric Medicine

Psychiatry

Pulmonology

Rehabilitation & Physiatry

Urology

Rheumatology

Neuro-Ophthalmology

Other

What type of patients do you see? (Select all that apply)
What type of patients do you see? (Select all that apply) is required.

Adult

Pediatric

What is your disease expertise? (Select all that apply)
What is your disease expertise? (Select all that apply) is required.

ADEM

Neuromyelitis Optica Spectrum Disorder

Optic Neuritis

Acute or Idiopathic Transverse Myelitis

Acute Flaccid Myelitis

Transverse Myelitis and suspected Multiple Sclerosis

Clinically Isolated Syndrome

Multiple Sclerosis

Systemic lupus erythematosus or Lupus

Sjogren's Syndrome

Sarcoidosis or Neurosarcoidosis

Spinal Stroke or AVM

Lyme Disease

MOG Antibody-Associated Disease

Other

SRNA has a public database of medical professionals who specialize in rare neuroimmune disorders on our website. If you would like us to add your information, please select “Yes” to give us permission to post your practice information (Optional)
SRNA has a public database of medical professionals who specialize in rare neuroimmune disorders on our website. If you would like us to add your information, please select “Yes” to give us permission to post your practice information is required.

Yes

If yes, please provide the website link to your online profile you would like us to use for your profile. (Optional)

SRNA hosts an Ask the Expert podcast series which covers a variety of topics relating to rare neuroimmune disorders. Are you interested in appearing as a guest expert on the podcast? (Optional)
SRNA hosts an Ask the Expert podcast series which covers a variety of topics relating to rare neuroimmune disorders. Are you interested in appearing as a guest expert on the podcast? is required.

Yes, I am interested in appearing as a guest on the Ask the Expert podcast

What language(s) do you speak? (Select all that apply) (Optional)
What language(s) do you speak? (Select all that apply) is required.

Arabic

Bengali

English

French

German

Hindi

Japanese

Mandarin

Portuguese

Russian

Spanish

Other

Other (Optional)

How did you hear about SRNA? (Select all that apply)
How did you hear about SRNA? (Select all that apply) is required.

Internet search

Social media

Medical professional

Another organization

Friend or family member

Other

Do you have the Certification in Rare Neuroimmunologic Disorders (CRND)? (Optional)
Do you have the Certification in Rare Neuroimmunologic Disorders (CRND)? is required.

Yes

I would like to be contacted about research and clinical trials and studies

If you are interested in receiving our weekly blog please check the box below. (Optional)
If you are interested in receiving our weekly blog please check the box below. is required.

I am interested in receiving SRNA's weekly blog

I am interested in receiving pediatric-specific emails

Please note - if you sign up for our Research, Blog, or Pediatric email lists, you will automatically be subscribed to receive emails from SRNA.

Your donation will be securely processed.

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Other

Membership Form

Contact Information

First Name Middle Name (Optional) Last Name

Preferred Language (Optional)

Race (Optional)

Ethnicity (Optional)

Address Line 1 Address Line 2 (Optional)

CountryUnited States Postal Code City State/Province (Optional)

Email Home Phone (Optional) Mobile Phone (Optional)

Yes, sign me up for email updates.

Remember me so that I can use FastAction next time.

(Optional)

Additional Information

Postal mail

Volunteer

How did you hear about SRNA? (Select all that apply)
How did you hear about SRNA? (Select all that apply) is required.

Internet search

Social media

Medical professional

Another organization

Friend or family member

Other

I would like to be contacted about clinical trials and studies

If you are interested in receiving our weekly blog please check the box below. (Optional)
If you are interested in receiving our weekly blog please check the box below. is required.

I am interested in receiving SRNA's weekly blog

I am interested in receiving pediatric-specific emails

Please note - if you sign up for our Research, Blog, or Pediatric email lists, you will automatically be subscribed to receive emails from the SRNA.

Your donation will be securely processed.