Mailing List Update Form
Thank you for taking the time to help us update our records and get to know you better!  As a social
service agency the MGA is dedicated to helping all people with MG, their family and friends. Some
of the questions we ask are to gather date for grant writing.  Foundations are interested in a variety
of issues so we thank you for your responses. Your information will not be shared with outside
sources in connection with your name.
Name:

Address:

City:

State:

Zip Code:

Phone:

E-mail:


Are you:



Do you find our newsletter Connections
helpful or interesting?

What do you like best?


Would you like to see a particular topic
featured? If so, what?

Would you like to receive the newsletter by
e-mail? That helps us save about
$10/year/person and you'll receive it in color

Do you attend an MG support group in your
area?

Which Support Group is closest to you?


What do you find most helpful about MGA?


Is there anything we can do to help you or
improve our services?


Do you feel that your neurologist is
informed enough about MG that you would
recommend him/her?

If yes, what is their name and where are
they located?


Would you consider becoming a member or
making a contribution to the MGA in 2010?
If yes, thank you so much!

Do you give to the United Way?
You can designate the MGA if you give to
the United Way - our donor # is 605

Optional Question for funding purposes -
Does your household earn less than $48,000
a year?

Optional Question for funding purposes -
What do you consider your ethnic/racial
group?

Optional Question for funding purposes -
What is your birth year?

Optional Question for funding purposes -
Do you have health insurance?


The MGA is always looking for ways to
increase our image in the community.
Would you be willing to:





Would you like someone from the MGA
office to call you for further information or
support?


Any other comments?
MG Patient

Family Member
 Friend

Health Professional
Yes
No
Yes
No
Yes
No
N/A
Yes
 No
Yes
No
Yes
No
Yes
 No
Yes
No
Allow the MGA to use a quote of yours about
the importance of our services or programs?
Allow us to take and use a picture of you for
publicity?
Allow us to videotape you for an interview on
our website or MGA promotional video?
Yes
No