Family/Guardian Information


 

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Phone*
Email*
Confirm Email*

 


Tell us about the person with CFC syndrome in your life.

 

Individual's First Name*
Individual's Last Name*
Individual's Gender*
  • Female
  • Male
Individual's Date of Birth (mm/dd/yyyy)*
Your relationship to this person*
Please select one of the following options that best describes the individual's genetic DNA testing results*
  • BRAF
  • KRAS
  • MEK1
  • MEK2
  • Testing Done - No Mutation Found
  • Testing Not Done




Other Information

 

I wish to receive the organization newsletter via email*
  • Yes
  • No
If U.S. address, you may indicate you prefer to receive a paper copy of the newsletter
  • No
  • Yes
Would you like your family's information included in the CFC Family Directory? Information provided in this directory is strictly for the private use of CFC Families.*
  • Yes, I would like to be included in the CFC Family Directory
  • No, I do not want to be included in the CFC Family Directory
Additional Comments

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