CdLS USA Foundation: Request Publications

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

CdLS-USA Informational Material
Request Form

To request informational materials, please submit this simple form:

TELL US ABOUT YOU:

(Fields marked with an asterisk (*) are required.)

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

Have you contacted the CdLS Foundation before? * Yes No

TELL US ABOUT THE PERSON WITH CdLS
IN YOUR LIFE:

Name
Age
Date of Birth	,
Your Relationship to this Person *
	(Please use the "Additional Comments" section below to complete description if necessary.)

PUBLICATIONS:

I would like to receive the following sample publications:
"Facts About CdLS" brochure
"Reaching Out" newsletter
CdLS Foundation brochure
"Facing the Challenges: A Guide to CdLS" book
Awareness Flyer(s)
"Find One Child" DVD(s)

CdLS-USA Informational MaterialRequest Form

TELL US ABOUT YOU:

TELL US ABOUT THE PERSON WITH CdLSIN YOUR LIFE:

PUBLICATIONS:

ADDITIONAL COMMENTS: (500 characters maximum)

CdLS-USA Informational Material
Request Form

TELL US ABOUT THE PERSON WITH CdLS
IN YOUR LIFE: