Please complete this form to update your information as well as provide information about your genetic test results.Please enable JavaScript in your browser to complete this form.Please enter the ORIGINAL email address that you used for the C3 Registry. This is the address at which you are currently receiving communications from us. *We need this address to match you to your original registry record.If you would like to update your email address, please provide a NEW email address here.If you do not wish to update your email address, leave this field blank.The Registrant's (patient's) full name *FirstLastIf you are filling out this form on behalf of a child or relative, enter their name here. If you are the registrant, enter your own name.Current phone number Current City and State/Province *Example: Boston, MA Current Country *Current Neurologist Name and InstitutionIf you are being seen by a neurologist for your muscular dystrophy, please provide their full name and institutional affiliation. Example: Dr. John Smith, NYU Medical Center.Current ambulatory (walking) status *Can walk unaided, without difficultyCan walk unaided, with moderate difficultyCan walk, with use of mobility aid (i.e. cane, crutches)Cannot walk (full-time wheelchair user)Genetic Diagnosis *I was diagnosed with LGMD2A by a genetic test.I do not have a genetic diagnosis, and I would like information about free testing.I do not have a genetic diagnosis, and I do not want information about free testing.Genetic Report and Supporting Documents Upload Click or drag files to this area to upload. You can upload up to 5 files. If you would like to share your genetic report and other supporting medical documentation with C3, please upload it here. We will hold your individually identifiable information in the strictest of confidence, and will only use or disclose it to third parties with your specific consent.Genetic Mutation: If you are unable to upload your genetic report, but know your mutation(s), please enter them here:If you have uploaded your genetic report, you do not need to enter your mutations here.GDPR Agreement and Privacy Statement *I consent to having C3 store my submitted information so that I can be contacted in the future. By providing your individually identifiable health care information to C3, you authorize the use of such data in our aggregate patient registry, which is used to document the prevalence, genotypes and phenotypes of this condition and may be used for research purposes to identify possible diagnostic or treatment options. C3 is not a health care provider and is not a covered entity under HIPAA. We may contact you to discuss your registration, and you always have the right to either decline to discuss it further or to withdraw this authorization, in which case we will remove your individually identifiable information from the registry. Your registration will be stored in a secure electronic database. CommentSubmit Form