American Nystagmus Network - Online Registration

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Online Registration Form

If you wish to register and pay online using your VISA, Mastercard, American Express, or Discover credit or debit cards. Pease fill out the following form. After you submit the form, you will be taken to a page that will allow you to pay with your credit card via PayPal. International members may also use this option.

You will be required to register with PayPal if you do not already have a userid and password. This registration is much like register for any e-commerce site such as Amazon.com and is straight forward and entirely secure. For more information on PayPal go to www.paypal.com

Registration Form

ANN Membership Information

Is this a New Membership or Renewal?   New Renewal
Title: Mr.        Ms.       Mrs.         Other (Please Specify)            Other:
First Name:           Last Name:
Address Line 1:
Address Line 2:
City:          State:         Zip:
Country:
Phone:                             Fax:
Email (Type Carefully):

ANN Questionnaire

ANN collects information to assist in service delivery to its members and to provide data and contact information to the medical community. Kindly complete the questionnaire and include it with your completed membership form. This questionnaire is optional.

Date of Birth of the Person with Nystagmus:
Relationship to person with Nystagmus: Specify:
How did you find out about ANN, Inc: Specify:

To the best of your understanding, what type of Nystagmus does the person with Nystagmus have?

May ANN, Inc. give your name and address to other members? Yes No

May ANN, Inc. give your name and address to medical Researchers? Yes No

ANN, Inc. Caveat: Though discussions on specific problems are permissible and expected, remember that no posting here shall constitute professional health care or medical advice, and you should never rely on any contribution to this, or any, Internet discussion forum on important medical or professional health care questions. Indeed, no Internet discussion forum is a substitute for the careful advice and treatment of a competent professional health care provider or doctor.

ANN, Inc. is a volunteer, nonprofit organization for persons and families involved with nystagmus. ANN, Inc. does not diagnose or treat, or provide professional counseling. It is involved in self-help, while trying to promote research and education, among other goals contained in its mission statement.