Aware-RSD Application To Join Aware-RSD

* CONFIDENTIAL*

Personal Information:

First Name & Last Name:

MSN/Hotmail/Net Passport Nickname:

Full Mailing Address:

Home & Cell #’s:

All e-mail addresses:

Birthday:

Wedding Anniversary:

Any Teen(s) between 13-16?

Medical History:

How did you acquire your condition?

Length of time you have been afflicted:

Body Parts Affected:

Other Information:

List any interests/hobbies:

List online Support Groups:

List face to face Support Groups:

Verification Process:

"I,    ___________________   [SU1] , have read “Aware-RSD” *Application Process & Information, *Terms of Use, *Disclaimer and *Privacy Policy and by signing this application shows that I agree to them. The direct links are Application Process & Information and Disclaimer and Terms of Use and Privacy Policy . I also am verifying all information I wrote/typed on this application is true. I do understand that if any information is found to be untrue I will be denied as a member and if given membership I maybe removed of all membership capabilities ASAP.

Sign Your Name: ________________________[SU2] 

Print Full Name: _________________________[SU3] 

Date Completed: _________________________[SU4]