Worldwide Sharing Submission Form


This form is for those wishing to network with others that are dealing with Alzheimers or other forms of disease. It IS NOT a random PenPal form. Please fill in the following information.

Your Name:(Do not hit RETURN)

Your Nickname:(Do not hit RETURN)

Your ICQ number:(Do not hit RETURN)

Your IRC Information:(Do not hit RETURN)

Your Location:(Do not hit RETURN)

Please tell me a little about your situation.
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