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Register Your Stroke Support Group 2014

 

Stroke Support Group logo

If you submit a group called Stroke Support Group, we will add the meeting place name, as defined on this form, to your group name.

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  Primary Contact Information:

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Name:

 

 

   

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City/State/ZIP:

 

    

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If you respond and have not already registered, you will receive periodic updates and communications from National Stroke Association.

 


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Group Activities: 

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Question - Required - What does your group provide? Select all that apply.
Please make between 1 and 12 selections from the choices below.

 

(Maximum response 255 chars, approx. 5 rows of text)

 

Group Type: 

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Question - Required - Which category (or categories) best describes your group?
Please make between 1 and 4 selections from the choices below.

 

(Maximum response 255 chars, approx. 5 rows of text)

 

Group Specialty: 

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Question - Required - Which category (or categories) best describes your group?
Please make between 1 and 8 selections from the choices below.

 

StrokeSmart® Magazine:

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We will send the magazines to the address listed above. If you prefer the magazine to be sent to a different address, please specify that address below:

 

(Maximum response 255 chars, approx. 5 rows of text)

   


 

Submitting this form indicates that you give National Stroke Association permission to post all data from this form on the National Stroke Association website (excluding those items marked for internal use only). 

If you have any questions or concerns, please contact us by email at supportgroups@stroke.org

Disclaimer: The information provided on the form will be added to our listing within 3-5 business days.

   Please leave this field empty