National Epidermolysis Bullosa Awareness Week Relay-Rally SIGN UP

Let's jump-start this party! Please complete the following information form, with the assurance that all details will remain completely confidential.

The primary form of communication will be email, in order to be most productive and keep expenses reasonable. Therefore, please be sure to give an email address if you wish to receive updates.

* If you prefer not to disclose a complete physical address or phone number, please indicate your general location so that our response can be specific to your region.

NAME:

*ADDRESS LINE 1:

*ADDRESS LINE 2:

CITY:

STATE/PROVINCE:

ZIP CODE/POSTAL CODE:

EMAIL ADDRESS:

* PHONE NUMBER:

Do you, or a family member or close friend, have EB? Please give details:

Can you participate on-site for the entire National Epidermolysis Bullosa Awareness Week route from New York City to Stanford, California?

Would you like to attend a Rally in one of the destination locations October 25-31, 2007?

Can you participate on-site for some part of the route? If so, in what area can you participate?
(Please see Route page for details.)

Do you have friends who might want to help? Please encourage them to visit this website, or if you're sure they won't mind, pass on their email addresses (insert a comma between each one):

I wish to receive newsletter updates regarding the EB Relay and this website

I can't physically participate on-site, but I would like to know more about the SECOND LIFE "Walk a Mile in My Shoes" EB Relay in cyberspace, that I can participate in from my computer

Please tell us anything else important about yourself and how you are able to participate:

I Want More Info!