IMDSG Registration
    This is where group facilitators may register for affiliation with the International Macular Degeneration Support Group. You will receive notice when your request has been accepted. Thank you for your interest in this important outreach effort!

Name of your center or organization:


Check one:

New registration
Update registration

Check all that apply to your group:

Retirement Community
Library
Clinic or Hospital
Senior Organization
Place of Worship
Private Group Home
Other (describe):

Check the status that best describes your participation:

Online Affiliate (will mostly attend live webcasts)
Offline Affiliate (will mostly access recorded sessions)

Person/s in charge of group:
1.

2.

Email address/es of above person/s:
1.

2.

Web site address (if applicable):
http://

Postal address (Street or P.O. Box/City/State or Province/Postal Code):


Average expected attendance at meetings:



I have read and agree to adhere to the policies and procedures of the IMDSG.

Permission is given to publish the above contact information on the IMDSG web site for others who wish to join the group at this location.

Comments or questions?