Adult Virtual Support Group – January 8, 2021 Registration for virtual support group Name* First Last Tell us about yourself!*Phone*Address Where You Will Be Participating From* Street Address City State / Province / Region Email* Enter Email Confirm Email Consent* I am an adult (18+) impacted by a swallowing disorder. I live in the United States. I recognize that this is not a replacement for medical advice. I am available for the entirety of the Virtual Support Group Meeting. Emergency Contact*In case of emergency during the virtual support group meeting, we request that you provide emergency contact information. First Last Relationship to Emergency Contact* Emergency Contact Phone* Δ