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Cure LBSL Contact Registry

3.About this form

By filling out this form, you are helping increase our understanding of where LBSL patients, families, clinicians, and researchers are located around the world.  Based on your responses, Cure LBSL will be able to create and share resources in the preferred languages of our diverse international community.  

Please let us know a little bit about yourself and what types of communication you would like in the future.  (Note: all questions are optional, and your data will be treated with the utmost care to protect your privacy).  
1.How may we address you?
2.What is your first name?
3.What is your last name (surname)
4.What email address would you like us to use for communication? 
5.What language(s) do you prefer for communication?
6.In what country do you live?
7.Please send me information about:
8.What is your relationship to the LBSL community?  (please check all that apply)
9.Please share anything else you would like for our team to know.  We look forward to connecting with you!
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