Share Your Coats' Story
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First Name
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Last Name
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Email Address
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Do you have Coats' Disease?
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No
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Are you a parent of a child with Coats' Disease?
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Yes
No
Other
Child's Name (if you are a parent of a Coats' patient)
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Name of treating physician (if applicable)
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Share Your Story
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Permissions/Releases
By checking this box, I grant Jack McGovern Coats' Foundation permission to use my story and photos for online and printed material related to the Foundation.
I DO NOT grant Jack McGovern Coats' Foundation permission to use my story and photos in online or printed material.
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