DOC16 || Membership

Join The Disorders of Chromosome 16 Foundation

Name:
Phone:
E-mail:
Address:
City
State
Zip
Child's Name:
Date of Birth:
Diagnosis:
Any health problems related to the disorder?
Tell us your "story" (whatever you'd like to share about your family's experience with the disorder). (Send scanned photos or send them via post to this address.)
You may use our story and/photos in newsletters, promotional brochures, etc.	Yes No
You may give our information out to other families in the registry.	Yes No
Would you like to have a role in the Foundation?	Board of Directors Newsletter Web site Peer support Maintain database Fundraising Other (We can use all the help we can get!)