DOC16 Membership Form

Join the Disorders of Chromosome 16 Foundation

Name:
Email Address:
Phone:
Address:
City:
State:
Zip Code:
Child's Name:
Child's 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).
You may use our story and/or photos on the website, in newsletters, promotional brochures, etc.	Yes No
Would you like to have a role in the foundation?	Board of Directors Website Newsletter Peer Support Fundraising Other

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