EB-ONE is a support group for families living in Massachusetts, New Hampshire, and Rhode Island who
have lost someone to Epidermolysis Bullosa or are caring for someone with EB (including yourself). Our
goal is to lend support to these patients or families emotionally & physically. We also keep our doors open
for anyone who may be interested in learning about EB because awareness is the key to support. Please
fill in the registration form to the best of your ability because the information will help us to be a better
support system.
All information is confidential and is only used for contact and data collection.
UNFORTUNATELY, DUE TO CONTINUOUS SPAM FROM
THE SAME WEBSITE, I HAVE REMOVED THE ON-LINE
FORM TEMPORARILY. PLEASE PRINT OUT THE
PRINTABLE VERSION, OR EMAIL EB-ONE at
ebone@everlastingbutterfly.com .
Thank you for your patience and understanding.
Sincerely,
Troy Medeiros
(If you are not over 18 years of age, you will need a parent's or guardian's permission in writing.)
NO
If not, please explain your interest or relationship.
Do you know of other family members or friends that are or have suffered from EB?
NO
NO
Please explain what you would like to get out of this group.
The location of the meetings may vary from month to month. We will try and centralize the meeting
locations according to attendee's locations. Do you have a preference due to comfort level on where the
meetings are held?Such as a home, church, hospital, or hall.
YES
NO
Have you ever attended any kind of support group before?
YES
NO
If your answer was yes. What did you like or
dislike about the group?
Please list any particluar questions that you may have. This wil allow usthe time to research and give you a
more complete answer. Also, please list any particular articles or information you would like. We will do our
best to attain items requested.
THANK YOU FOR TAKING THE TIME TO FILL OUT THIS REGISTRATION FORM. WE HOPE
THAT THE INFORMATION SUPPLIED WILL HELP THE GROUP BE MORE BENEFICIAL TO ALL.
ALL INFORMATION IS CONFIDENTIAL, AND WILL ONLY BE USED FOR CONTACT AND DATA COLLECTION ONLY.