When you provide your contact information as a sponsor of EBAN, it simply means that you support EBAN's goals and you will be able to help us reach our goals by signing petitions, calling or writing our legislators or help us in other projects we might have in the works.

Please add your contact information if you wish to participate!

PLEASE NOTE:
If you would like us to email you when we have updates to the website, any EB-related news, or when we have announcements of upcoming activities, you may join our *newsletter* by filling out the appropriate field in this form. THANK YOU! 

Fields with a * are Mandatory:

E-mail Address: * Full Name * Address City, State, Zip * Phone Number Please tell us who you are and how you're related to an EB patient (ex.: mother, grandfather, patient is self, etc) * Form of EB of the patient* Please state unknown if you do not know * Would you like to receive our newsletter? (If yes, we will add you to our low-volume group) * Yes No Comment, Question or Suggestion: * Required

Please Note: 

1. We NEED to have a way to contact you. Forms that are submitted without an email address OR physical mailing address OR phone number (one of these is necessary) will be discarded. If you prefer not to disclose a complete physical address, it is important that you indicate your general location, i.e., city and state/province. 

2. We update our list and add new supporters to the newsletter once every other month. Thank you for your patience and Thank you for your support!

Please do not submit false or empty forms.  

Copyright 2008 © Please Read our Disclaimer & Privacy Policy
 Epidermolysis Bullosa Action Network
16613 Milan De Avila, Tampa, Fl 33613
Telephone:1-813-325-1955
EBAN is a 501 (c) (3) non profit, tax exempt organization designated by the Internal Revenue Code