Taylor Bug Kisses Foundation

Smith-Magenis Syndrome Database

*A confirmation email will be sent to you after you fill out this form. Make sure to check your junk mail for this confirmation.

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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 only
Family contact purposes
Both

Information for family to family contact

Share only my email
Share only my phone number
Share only my address
Share my email, phone number and address

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

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

Would you like to be listed on the SMS map?

Yes
No
I am already on the map

What information do you want listed on the map?

First name and State
Full name and State
Name and full address
Name, State and age of child

Would you like to receive our newsletter?

Yes
No, thank you
I already receive it

Other comments

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