Date:

Mr. Ms. Mrs.

Full Name:

If minor, state parents names:

Address:


City:   State:

Zip code:

Country:

Home telephone number:

E-mail:

Male Female

Birthday (month/day/year):

Marital status:

If married, please state anniversary:

Education:


Interests and Hobbies:


Briefly state how you found the IFOPA?:


Age of first symptoms:

Age of diagnosis:

Your physician's name:

Physician's address/telephone :

I have sent my $25 membership fee in the mail (US currency, please).

I have paid by Paypal. Use Paypal icon at the bottom of this form. My transaction ID is:

Please enroll me as a sponsored member, which will allow me to waive the membership fee.

(For International members only) Please mail the Connection newsletters to me.

(For International members only) I would like to view the Connection newsletters online only. Email me when the newsletters are ready to view. My email address is:

Please send me a copy of What is FOP? A Guidebook for Families

Please send me a copy of What is FOP? Questions and Answers for the Children.

Please add me to FOP online, a gathering place online for members to share their experiences. (In English)
(More information | Guidelines)

Please add me to FOPlatinoamerica, a gathering place online for members to share their experiences in Spanish.
(More information | Guidelines)

Please add me to FOPbrasil, a gathering place online for members to share their experiences in Portuguese.
(More information | Guidelines)

I do not want my name listed in the IFOPA directory or any IFOPA publications.

You may include my picture on the web site picture page with the following caption:


We also ask that you supply a recent photo of yourself for the IFOPA scrapbook.

Please press submit to give this form directly to the IFOPA.