{"id":5100,"date":"2025-05-15T16:21:32","date_gmt":"2025-05-15T16:21:32","guid":{"rendered":"https:\/\/www.lgmd-info.org\/?page_id=5100"},"modified":"2025-05-22T18:07:11","modified_gmt":"2025-05-22T18:07:11","slug":"individuals-with-lgmd-spotlight-interview-form","status":"publish","type":"page","link":"https:\/\/www.lgmd-info.org\/ja\/spotlights\/individuals-with-lgmd-spotlight-interview-form\/","title":{"rendered":"Individuals with LGMD Spotlight Interview Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1456px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_11' style='display:none'><div id='gf_11' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11'  action='\/wp-json\/wp\/v2\/pages\/5100' data-formid='11' novalidate data-trp-original-action=\"\/ja\/wp-json\/wp\/v2\/pages\/5100#gf_11\"><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdRLEUrAAAAAGnr_HnMYRSClVxaAZqnJUgD7nmo' data-tabindex='0'><input id=\"input_fff23a27132e63513a0dc6fcf9b904a5\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_fff23a27132e63513a0dc6fcf9b904a5\" value=\"\"\/><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_11_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u540d\u79f0<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_11_1'>\n                            \n                            <span id='input_11_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_11_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_1_3' class='gform-field-label gform-field-label--type-sub'>\u6700\u521d<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_11_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_1_6' class='gform-field-label gform-field-label--type-sub'>\u6700\u5f8c<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_11_24\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_24\" ><label class='gfield_label gform-field-label' for='input_11_24'>\u96fb\u5b50\u30e1\u30fc\u30eb<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_11_24' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_11_27\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_27\" ><p><i>Your last name and email address will remain private and will not be publicly visible.<\/i><\/p><\/div><div id=\"field_11_20\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_20\" ><label class='gfield_label gform-field-label' for='input_11_20'>\u5e74\u9f62<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_20' id='input_11_20' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_20\" \/><div class='gfield_description instruction' id='gfield_instruction_11_20'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_11_3\" class=\"gfield gfield--type-address gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_11_3' >\n                        <input type='hidden' class='gform_hidden' name='input_3.4' id='input_11_3_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_11_3_6_container' >\n                                        <select name='input_3.6' id='input_11_3_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >\u30a2\u30eb\u30bc\u30f3\u30c1\u30f3<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >\u30d0\u30f3\u30b0\u30e9\u30c7\u30b7\u30e5<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >\u30ab\u30ca\u30c0<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >\u30d5\u30e9\u30f3\u30b9<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >\u7c73\u56fd<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_11_3_6' id='input_11_3_6_label' class='gform-field-label gform-field-label--type-sub'>\u56fd\u540d<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_11_25\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_25\" ><label class='gfield_label gform-field-label' for='input_11_25'>LGMD Subtype (if known)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_11_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='LGMD 2A \/ LGMD R1 calpain3-related' >LGMD 2A \/ LGMD R1 calpain3-related<\/option><option value='LGMD 2B \/ LGMD R2 dysferlin-related' >LGMD 2B \/ LGMD R2 dysferlin-related<\/option><option value='LGMD 2C \/ LGMD R5 y-sarcoglycan-related' >LGMD 2C \/ LGMD R5 y-sarcoglycan-related<\/option><option value='LGMD 2D \/ LGMD R3 a-sarcoglycan-related' >LGMD 2D \/ LGMD R3 a-sarcoglycan-related<\/option><option value='LGMD 2E \/ LGMD R4 b-sarcoglycan-related' >LGMD 2E \/ LGMD R4 b-sarcoglycan-related<\/option><option value='LGMD 2F \/ LGMD R6 d-sarcoglycan-related' >LGMD 2F \/ LGMD R6 d-sarcoglycan-related<\/option><option value='LGMD 2G \/ LGMD R7 telethonin-related' >LGMD 2G \/ LGMD R7 telethonin-related<\/option><option value='LGMD 2H \/ LGMD R8 TRIM32-related' >LGMD 2H \/ LGMD R8 TRIM32-related<\/option><option value='LGMD 2I \/ LGMD R9 FKRP-related' >LGMD 2I \/ LGMD R9 FKRP-related<\/option><option value='LGMD 2J \/ LGMD R10 titin-related' >LGMD 2J \/ LGMD R10 titin-related<\/option><option value='LGMD 2K \/ LGMD R11 POMT1- related' >LGMD 2K \/ LGMD R11 POMT1- related<\/option><option value='LGMD 2L \/ LGMD R12 anoctamin5- related' >LGMD 2L \/ LGMD R12 anoctamin5- related<\/option><option value='LGMD 2M \/ LGMD R13 Fukutin-related' >LGMD 2M \/ LGMD R13 Fukutin-related<\/option><option value='LGMD 2N \/ LGMD R14 POMT2- related' >LGMD 2N \/ LGMD R14 POMT2- related<\/option><option value='LGMD 2O \/ LGMD R15 POMGnT1-related' >LGMD 2O \/ LGMD R15 POMGnT1-related<\/option><option value='LGMD 2P \/ LGMD R16 a-dystroglycan-related' >LGMD 2P \/ LGMD R16 a-dystroglycan-related<\/option><option value='LGMD 2Q \/ LGMD R17 plectin-related' >LGMD 2Q \/ LGMD R17 plectin-related<\/option><option value='LGMD 2R \/ \/ Myofibrillar Myopathy' >LGMD 2R \/ \/ Myofibrillar Myopathy<\/option><option value='LGMD 2S \/ LGMD R18 TRAPPC11- related' >LGMD 2S \/ LGMD R18 TRAPPC11- related<\/option><option value='LGMD 2T \/ LGMD R19 GMPPB-related' >LGMD 2T \/ LGMD R19 GMPPB-related<\/option><option value='LGMD 2U \/ LGMD R20 ISPD-related' >LGMD 2U \/ LGMD R20 ISPD-related<\/option><option value='LGMD 2V \/ Pompe Disease' >LGMD 2V \/ Pompe Disease<\/option><option value='LGMD 2W \/ PINCH-2 related myopathy' >LGMD 2W \/ PINCH-2 related myopathy<\/option><option value='LGMD 2X \/ BVES-related myopathy' >LGMD 2X \/ BVES-related myopathy<\/option><option value='LGMD 2Y \/ TOR1AIP1-related myopathy' >LGMD 2Y \/ TOR1AIP1-related myopathy<\/option><option value='LGMD 2Z \/ LGMD R21 POGLUT1-related' >LGMD 2Z \/ LGMD R21 POGLUT1-related<\/option><option value='LGMD R22 Collagen 6-related (Bethlem myopathy recessive)' >LGMD R22 Collagen 6-related (Bethlem myopathy recessive)<\/option><option value='LGMD R23 LAMA2-related' >LGMD R23 LAMA2-related<\/option><option value='LGMD R24 POMNGT2-related' >LGMD R24 POMNGT2-related<\/option><option value='LGMD R25 POPDC1-related' >LGMD R25 POPDC1-related<\/option><option value='LGMD R26 POPDC3-related' >LGMD R26 POPDC3-related<\/option><option value='LGMD R27 JAG2-related' >LGMD R27 JAG2-related<\/option><option value='LGMD R28 HMGCR-related' >LGMD R28 HMGCR-related<\/option><option value='LGMD R29 SNUPN-related' >LGMD R29 SNUPN-related<\/option><option value='LGMD 1A \/ Myofibrillar Myopathy' >LGMD 1A \/ Myofibrillar Myopathy<\/option><option value='LGMD 1B \/ Emery-Dreifuss Muscular Dystrophy (EDMD)' >LGMD 1B \/ Emery-Dreifuss Muscular Dystrophy (EDMD)<\/option><option value='LGMD 1C \/ Rippling Muscle Disease' >LGMD 1C \/ Rippling Muscle Disease<\/option><option value='LGMD 1D \/ LGMD D1 DNAJB6- related' >LGMD 1D \/ LGMD D1 DNAJB6- related<\/option><option value='LGMD 1E \/ Myofibrillar Myopathy' >LGMD 1E \/ Myofibrillar Myopathy<\/option><option value='LGMD 1F \/ LGMD D2 TNP03- related' >LGMD 1F \/ LGMD D2 TNP03- related<\/option><option value='LGMD 1G \/ LGMD D3 HNRNPDL-related' >LGMD 1G \/ LGMD D3 HNRNPDL-related<\/option><option value='LGMD 1H \/' >LGMD 1H \/<\/option><option value='LGMD 1I \/ LGMD D4 calpain3-related' >LGMD 1I \/ LGMD D4 calpain3-related<\/option><option value='LGMD D5 Collagen 6-related (Bethlem myopathy dominant)' >LGMD D5 Collagen 6-related (Bethlem myopathy dominant)<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_11_26\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_26\" ><label class='gfield_label gform-field-label' for='input_11_26'>LGMD Subtype Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_11_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_23\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_23\" ><label class='gfield_label gform-field-label' for='input_11_23'>\u4f55\u6b73\u3067\u8a3a\u65ad\u3055\u308c\u307e\u3057\u305f\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_11_23' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_23\" \/><div class='gfield_description instruction' id='gfield_instruction_11_23'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/div><div id=\"field_11_6\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_6\" ><label class='gfield_label gform-field-label' for='input_11_6'>\u6700\u521d\u306e\u75c7\u72b6\u306f\u3069\u306e\u3088\u3046\u306a\u3082\u306e\u3067\u3057\u305f\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_11_6' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_7\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_7\" ><label class='gfield_label gform-field-label' for='input_11_7'>LGMD\u3092\u60a3\u3063\u3066\u3044\u308b\u5bb6\u65cf\u304c\u4ed6\u306b\u3044\u307e\u3059\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_11_7' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_8\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_8\" ><label class='gfield_label gform-field-label' for='input_11_8'>LGMD\u3068\u5171\u306b\u751f\u304d\u3066\u3044\u304f\u4e0a\u3067\u3001\u6700\u3082\u56f0\u96e3\u3060\u3068\u611f\u3058\u308b\u3053\u3068\u306f\u4f55\u3067\u3059\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_11_8' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_9\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_9\" ><label class='gfield_label gform-field-label' for='input_11_9'>\u6700\u5927\u306e\u529f\u7e3e\u306f\u4f55\u3067\u3059\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_11_9' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_10\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_10\" ><label class='gfield_label gform-field-label' for='input_11_10'>LGMD\u306f\u4eca\u306e\u3042\u306a\u305f\u306b\u3069\u306e\u3088\u3046\u306a\u5f71\u97ff\u3092\u4e0e\u3048\u3066\u3044\u307e\u3059\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_11_10' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_11\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_11\" ><label class='gfield_label gform-field-label' for='input_11_11'>LGMD\u306b\u3064\u3044\u3066\u4e16\u754c\u306b\u77e5\u3063\u3066\u3082\u3089\u3044\u305f\u3044\u3053\u3068\u306f\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_11_11' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_12\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_12\" ><label class='gfield_label gform-field-label' for='input_11_12'>\u3082\u3057\u660e\u65e5\u3001\u3042\u306a\u305f\u306eLGMD\u304c \"\u6cbb\u308b \"\u3068\u3057\u305f\u3089\u3001\u307e\u305a\u4f55\u3092\u3057\u305f\u3044\u3067\u3059\u304b\uff1f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_11_12' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_13\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_13\" ><label class='gfield_label gform-field-label' for='input_11_13'>Please add a photo of yourself here:<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576' \/><input name='input_13' id='input_11_13' type='file' class='large' aria-describedby=\"gfield_upload_rules_11_13\" onchange='javascript:gformValidateFileSize( this, 1048576 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_11_13'>Accepted file types: jpeg, jpg, png, Max. file size: 1 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_11_13'><\/div><\/div><\/div><div id=\"field_11_15\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_15\" ><label class='gfield_label gform-field-label' for='input_11_15'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_11_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_11_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_11_15' class='gform_hidden' value='https:\/\/www.lgmd-info.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_11_14\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_14\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Photo and Promotional Release Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_14.1' id='input_11_14_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_11_14\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_11_14_1' >I agree to the Photo and Promotional Release Consent<\/label><input type='hidden' name='input_14.2' value='I agree to the Photo and Promotional Release Consent' class='gform_hidden' \/><input type='hidden' name='input_14.3' value='9' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_11_14'>I hereby consent to be interviewed, recorded, photographed, videotaped &\/or filmed by representatives<br \/>\nof the LGMD Awareness Foundation for purposes of publication, display or broadcast (print, web, digital<br \/>\ndisplay, and all other forms of media).<br \/>\nI agree that such interviews, recordings, articles, quotes, photographs, films, audio, or video and\/or any<br \/>\nreproductions of same in any form; including photos, articles, videos and\/or any other materials that I<br \/>\npersonally submit, are the property of the LGMD Awareness Foundation and I relinquish any present or<br \/>\nfuture claim for reimbursement for said photographic or film reproduction of my likeness or for said<br \/>\ntestimonials by me.<br \/>\nI hereby release the LGMD Awareness Foundation, its affiliates, employees, representatives, and agents<br \/>\nfrom any and all claims, demands, costs and liability that may arise from the use of these interviews,<br \/>\nrecordings, photographs, videotapes or films, and\/or any reproductions of same in any form, as described<br \/>\nabove.<br \/>\nI acknowledge that I have read this consent form in its entirety, or it has been read (or translated) to me,<br \/>\nand I have had the opportunity to ask questions about it and understand it. <\/div><\/fieldset><div id=\"field_11_17\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_17\" ><label class='gfield_label gform-field-label' for='input_11_17'>\u540d\u79f0<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_11_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_16\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_16\" ><label class='gfield_label gform-field-label' for='input_11_16'>*Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_11_16_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_11_16_valid' id='input_11_16_valid' \/><canvas id='input_11_16' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.lgmd-info.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_11_16_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_11_16_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' ><\/div><input type='hidden' id='input_11_16_data' name='input_11_16_data' value=''><\/div><\/div><div id=\"field_11_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_18\" ><label class='gfield_label gform-field-label' for='input_11_18'>Parent or Legal Guardian Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_11_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_18\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_11_18'>Parent or Legal Guardian name and signature required for individuals under age 18<\/div><\/div><div id=\"field_11_19\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_19\" ><label class='gfield_label gform-field-label' for='input_11_19'>Parent or Legal Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_11_19_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_11_19_valid' id='input_11_19_valid' \/><canvas id='input_11_19' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.lgmd-info.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_11_19_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_11_19_resetbutton' 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