Family Networking Request

If you would like to be put into contact with other individuals and families who are affected by Waardenburg Syndrome, fill out the following form and submit.

Your name

Other family members names. Please include their ages and relationship to you.


Email Address

Please indicate if you are interesting in talking with other families about the following issues by clicking the appropriate boxes.

Hearing Loss
Cochlear Implants
Educational Options
Hirschsprung's Disease
Cleft Lip and Palate
Cosmetic Surgery
Social Issues
Psychological problems related to facial differences
Other (Please indicate)

What do you hope to gain from Networking with other families?



Signature

Date
By typing your name in the box above you are giving us your permission to share your email address with other families dealing with WS.

SUBMIT

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