Join the Brain Buddies Group!

Disclaimer: The GrayMatters Foundation respects your privacy. The information you provide is used solely for the purpose of the Brain Buddies program and is intended for GrayMatters to use to stay in touch with the Brain Buddies and to connect them to others in the network. Your information is not sold or given out in any way.

Enter your Brain Buddie Information
I am a:
Other:
Salutation:
Buddie Name:	*required
If you are a filling this form out for someone else (a child, patient or survivor) please list your name as well:
Company:
E-mail Address:	*required
Website URL:
Address:	*required
City:
State:
Zip/Postal Code:
Country:
Phone:
Cell:
Buddie Birthday:
Is it okay for me to recognize your birthday on the Brain Buddies page of my website? Yes No
I Am Interested in Volunteering. Yes No
Would you like to receive the GrayMatters Newsletter via e-mail? Yes No
If you are a Brain Tumor Survivor, please fill out the information below:
Diagnosis Date:
Tumor Type:
Other:
Surgery Date 1:
Surgery Date 2:
Treatment Type:
Other:
At what location were you treated:
Is it okay for me to recognize your medical anniversary dates on the Brain Buddies page of my website? Yes No
Is it okay for me to send cards and goodies? Yes No
Talk to me: Tell me a little about yourself. What is your favorite color, food, animal, sports team? What are your hobbies? Let me know the sort of things that you would enjoy so that I can get to know you more. (Maximum 255 characters)
Please Enter a Security Code
Enter code: 438	Why Ask? This verifies you're a human user.

Join the Brain Buddies Group!

Enter your Brain Buddie Information

If you are a Brain Tumor Survivor, please fill out the information below:

Talk to me:

Please Enter a Security Code