GRUPPO ITALIANO SINDROME DI GOLDENHAR

FORM TO TAKE PART TO THE GROUP
Name and First Name: 
Born in: 
father/mother to: 
Born in: 
Date of birth:
Address: 
Telephone;
Mobile:
ZIP code: 
City: 
E-mail 


DECLARES

to be part of the Gruppo Italiano Sindrome di Goldenhar and to share its aims.

According to the Italian Laws n. 657/96 and n.196/2003 on processing personal data, the undersigned allows the Group to send his / her name to other people interested to or affected by the pathology belonging or not the above mentioned Group.