Support Group Signup Form

The Charcot-Marie-Tooth Association is working hard to provide the services of a support group to everyone. To do this, we need to know if people are interested in attending or starting support groups in their area.

You can use this form to tell us if you would attend a support group if there were one in your area. We'll keep your information on file and notify you if a support group begins meeting in your area. You can also tell us if you are willing to start a support group or are willing to help someone else start a group.

Required fields are marked with an asterisk().

Title:

First Name:

Middle Initial:

Last Name:

Address:

Address2:

City:

State:

Zip Code:

Daytime Phone:

Evening Phone:

Email:

Please check one of the following options:

	I am interested in attending a support group.
	I am interested in starting a support group.
	I am willing to help start a support group.

What is the greatest distance you are willing to travel to attend a support group meeting?

	10 miles
	25 miles
	50 miles
	100 miles

What is the best time for you?

	weekday, during the day
	weekday, in the evening
	Saturday morning
	Saturday afternoon

If you have additional comments or suggestions, please enter them here:

Charcot-Marie-Tooth Association 2700 Chestnut Street, Chester, PA 19013
Toll-Free (US Only): 1-800-606-2682 Phone: 1-610-499-9264 Fax: 1-610-499-9267
info@charcot-marie-tooth.org
© 2006 - 2008 Charcot-Marie-Tooth Association. All Rights Reserved.