TGCT Membership Application

Membership Application

If you have any questions or problems completing this form, please email TGCT Support at support@TGCTSupport.org. An asterisk (*) denotes fields that are required to submit this form.
All information provided will be kept strictly confidential and is for TGCT Support only. We are committed to protecting the privacy of our members. Any data or information that we share in any way is de-identified to protect confidentiality. TGCT Support is a program of The Life Raft Group.
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
I am a:*
If other, please specify:*
Patient Name*

First NameLast Name
The patient is my:*
If 'other' please specify:*
I am interested in:

Fundraising ActivitiesBeing matched with a Mentor (Mentors support TGCT patients through their journey).VounteeringSupport Groups
Where is your disease located?*
How did you hear about TGCT Support? Choose all that apply.

Another TGCT memberThe TGCT Facebook pagesInternet searchDoctorOther
If other, please specify*
Email address*
example@example.com
US Country code is 1. Look up country codes here.
Phone Number*

Country CodeArea CodePhone Number
This phone is my*
Preferred Method of Contact*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
WhatsApp Number*
Skype ID*
Preferred time to contact*
Please indicate time zone*
Please verify that you are human*
Should be Empty: