PSSG Questionnaire Form  - Fields marked with a Star * must be completed
 

Please supply your contact details
Your first name *		Surname *
Contact telephone number		E-Mail Address
Mobile telephone number
	Data Protection Please check this box	I understand that any personal details supplied will be held on file and used solely for the purposes of the PSSG in accordance with their constitution.
Q: WHAT WOULD YOU LIKE AND WHAT DO YOU EXPECT OUT OF A SUPPORT GROUP FOR POLAND'S SYNDROME?
		Please tick all that apply
Linking families in similar situations				Regular newsletter
Meetings with someone from the medical Profession				Get together once or twice a year to meet other families
	Other (Please state
Would you be prepared to help with any of the following? (Please tick all that apply)
Make people aware within your area.				Become a member
Help compile and distribute information on Poland Syndrome				Become a Committee member
Work on a newsletter				Fundraising
Help organise a get together for families affected by Poland Syndrome
Would you be willing for your telephone number/address to be given to other families  - For them to contact you.
If you are willing to be contacted please complete the address and telephone number fields at the top of this questionnaire and give a brief description below of how Poland Syndrome affects you or your child.
When you are ready press

either or            Thank You for completing this Questionnaire