Cornelia de Lange Syndrome Foundation, Inc.
302 West Main St. #100
Avon, CT USA 06001
Phone: 860-676-8166
Phone: 800-223-8355
Fax: 860-676-8337
email: info@cdlsusa.org

Family, Regional, and/or National Gathering Form

TELL US ABOUT YOU

Name *
Street Address *
City *
State/Province *  
Postal Code *
Country *  
Telephone
E-mail

TELL US ABOUT YOUR GATHERING

Name of Gathering *
Date(s)   ,   -   ,
Time    -  
Location *
City *
State or Province *  

What is the scope of your gathering?
Family/Regional     National

How many families do you expect to attend your gathering?
fewer than 10     10-25     more than 25

Will a local professional be speaking at the gathering?
Yes     No

If Yes, what is the professional's area of focus?

If Other, please specify:

Would you like a professional from our Scientific Advisory Council (SAC) to attend your gathering?
Yes     No

If available, from which top three areas of focus would you most like SAC representation?
(Hold down "Ctrl" key to make multiple selections)

Would you like a staff person from the CdLS-USA Foundation present at your gathering?
Yes     No

ADDITIONAL COMMENTS (500 character maximum)


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Last Updated 5/8/06
© CdLS-USA Foundation, Inc., 2006.