Join the Brain Buddies

Fill out the form below to join the Gray Matters Brain Buddies!

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 distributed in any way.

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Brain Buddie Information

I am a:
Other:
Salutation:
Buddie Name: *required
Buddie Birthday:
If you are a filling this form out for someone else (a child, patient or survivor) please list your name as well:
E-mail Address: *required
Phone:
Company:
Website URL:
If you would like to receive mail from GrayMatters such as birthday/anniversary cards, postcards, and other goodies, please fill out your mailing address below.
Address:
City:
State:
Zip/Postal Code:
Country:
I Am Interested in Volunteering.
            Yes    No

Brain Tumor Survivor Information

If you are a Brain Tumor Survivor, please fill out the information below:
Diagnosis Date:
Tumor Type:
Other:
Surgery Date:
At what location were you treated: 

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)


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