Register

Your Name*	Example: FirstName LastName
Street Address*
Address (cont.)
City*
State/Province*	use two letter abreviation
Zip/Postal Code*
Country	Example: USA
Work Phone	Example: 555-555-5555
Home Phone	Example: 555-555-5555
FAX	Example: 555-555-5555
E-mail*	Example: yourname@123.org
*Name of Sweetheart with Prader-Willi syndrome*
First Name*
Last Name*
*All Valentine sweetheart pictures will be displayed in the PWSA (USA) office*
	I Will email the picture
	I Will mail the picture
Filename of file for photo being e-mailed:

Complete this section if PWSA (USA) will create your letter:
	I need assistance with printing multiple copies of my letter
	How many copies do you require?

7th Annual Valentine Research Fund Campaign Register