Pediatric Swallowing Support Group: January 13 | National Foundation of Swallowing Disorders

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 a parent or caregiver of a child with a feeding or 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*