Your Name:
Your Mailing Address:
Your Email Address:
Your phone number:
When is the best time to call you ?
How are a family member
affected by MHE / MO / HME or
are you a family friend please
state briefly
Your d
ate of birth:
Names, ages, dates of birth child
or children affected by
MHE / MO / HME under 18 years
of age:
Names, ages, dates of birth child
or children NOT affected by
MHE / MO / HME under 18 years
of age:
Your Interests and Hobbies:
Child or Children's Interests and
Hobbies:
Briefly state how you found the
MHE Research Foundation?
Did you find the MHERF website
user friendly?
Please add comments if you
would like.
Yes
NO
Please contact me, as I am
interested in volunteering some
of my time to this foundation.
Please briefly fill in some of your
ideas or interests and an
approximant amount of time you
may have to volunteer (day, week
or month)
Please add me to the
MHE / MO /HME online, a
gathering place online for people
to share their experiences.
Yes
NO
Other Comments: