Please use this form to confirmation your subscription request to the facebook lissencephaly group.

The group is a closed list and we have a very strict privacy policy. Before approving you as a member, we may use the address and phone number to contact you to confirm your wish to join our group. This may seem a little outrageous just to join a facebook group, but it is the only way to ensure that the group stays a “parents/family only” group. I hope that you will understand this and still wish to join our group.

All members are listed in the online directory (current under construction). Items 5 and 6 will be kept STRICTLY confidential unless you select “List address information in the Directory”. If you choose No for this option, your address and phone number will not be listed. You will only be listed by your State and Country

* = Required Field

* 1. Your Name : * AS IT APPEARS ON FACEBOOK

2. E-mail Address:
(AOL members please remember to include @aol.com).

* 4. Password :
(This will be used to access the group member directory and is seperate from your yahoo password!)

Address Info :
Yes 
No 


Outside USA/CA, please select OTHER


Unlisted Country, please select OTHER

*

If your child or a child in your family has lissencephaly, please complete questions 7, 8 and 9, otherwise skip to item 9.


If Not listed, please select OTHER and enter below


If OTHER, please enter below


There is a lot of medical information which is passed around on the group. This is information from other parents on what may have worked for them. To try to protect the group members and you from any legal action which may result from mis-use of the group information, we ask that you read and agree to the following disclaimer statement. We cannot approve your request unless you agree to this disclaimer.

DISCLAIMER (Legal mumbo jumbo)

By accepting membership to the group, you release all group members from any
legal liability for advice given on the group. You also agree that the group is
not liabable for anything its individual members say or email they may send.
This advice should be used cautiously.  What may have worked from one
lissencephaly child may not work for your child.  CONSULT YOUR DOCTOR FIRST.

By accepting group membership you also certify that you will not use any
information obtained from the group for any type of medical research.  Your
personal experiences with the group can be shared, but please remember to
obtain permission before mentioning any group member by name/description.
The group discussions are meant only to help other parents cope with raising
a child with lissencephaly.  Anyone breaking this "rule" will be immediately
and permanently banned from this group.

I Agree
I do not agree