Taylor Bug Kisses Foundation Database

Smith-Magenis Syndrome Database

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Name: Email: Comment:

Your Name *

Email Address *

Name of Individual with SMS

Age/Date of birth of individual with SMS *

Your relationship to individual with SMS *

Street Address

Address Line 2

City

State/Province/Region *

Postal/Zip Code

Country

Phone Number

Country is a required field

How would you like your information used?

Statistical purposes onlyFamily contact purposesBoth

Information for family to family contact

Share only my emailShare only my phone numberShare only my addressShare my email, phone number and address

BEFORE we share your info. with other families....

We should contact you each timeWe do not need to contact you

Would you like to be listed on the SMS map?

YesNoI am already on the map

What information do you want listed on the map?

First name and StateFull name and StateName and full addressName, State and age of child

Would you like to receive our newsletter?

YesNo, thank youI already receive it

Other comments

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