Ehlers-Danlos Foundation of New Zealand

 

 

 

 

 Name………………………………………………………………………………   

Address…………………………………………………………………………...   

             ………………………………………………………………………………

             ………………………………………………………………………………

             ………………………………………………………………………………

              ………………………………………………………………………………

Phone no……………………………………………………………………………   

Mobile no……………………………………………………………………………...

Fax…………………………………………………………………………………...  

E-mail………………………………………………………………………………….

        I have:    Ehlers-Danlos Syndrome Type ……………………(if known)

                       A family member with EDS Type…………………….

                       Hypermobility Syndrome…………………………… (tick one)

                       A family member with HMS…………………………

There are……………..other members of my family with EDS/HMS

……. I am willing to be contacted by other members             (tick one)

……. I do not wish to be contacted at this time

 Please find the following amount enclosed:

Individual Subscription of $10.00                                          $…….….

Donation  (optional)                                                            $……….

                                                                               Total   $………..

                                                                                  

Please send payment to:

       THE EHLERS-DANLOS FOUNDATION OF NEW ZEALAND
  
   C/- JEN LONGSHAW, 1016 MATHESON ROAD, R.D.4., WAIPAWA, HAWKES BAY, NEW ZEALAND.

   
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