NEW DATA BASE

 

As part of PGC’s new and exciting restructuring we are creating a new data base.  We are asking everyone to please re-register with us, using the form below:

 

Mother’s Name _________________

 

Address:_______________________               

Phone:  _______________________

 

E-Mail:  _______________________

 

Father’s Name  ________________

 

Address:_______________________               

Phone:  _______________________

 

E-Mail:  _______________________

 

 

           

Name of Individual (s) with Galactosemia    Classic or Duarte    M/F               Date of Birth

 

________________________                    _____          ___         __________

 

________________________                    _____          ___         __________

 

 

Name of Siblings                                              Carrier Y, N or ?   M/F            Date of Birth

 

________________________                    _____          ___         __________

 

________________________                    _____          ___         __________

 

Please be sure to notify us of any changes in the future!

 

 

Please mail this form to:  

PGC

1519 Magnolia Bluff Dr

Gautier, MS  39553

 

 

Or E-Mail the info to : president@galactosemia.org

 

 

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