Moebius Connections

Note: Fields marked with * are required.

Full Name

First NameLast Name

Email Address (required for MSF communications with this program)

example@example.com

Do you reside in the United States?

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country

Do you speak English?

Preferred Language

Mobile Phone Number (Optional, but necessary if your preferred contact method is phone, texting, or WhatsApp.)

Please enter a valid phone number.Format: (000) 000-0000.

Permission to Receive Text Messages

Participant Type

Communication Style - What type of connection are you most comfortable with? (Select all that apply)

Communication Style (Teens) - What type of connection are you most comfortable with? (Select all that apply)

What stage or what challenges, if any, are you currently navigating? (Select all that apply)

What, if any, life experiences would you especially like to connect over? (Select all that apply)

What is the age of your child? (OPTIONAL)

This may help us to better partner you with another parent.

What is your relationship to a person with Moebius syndrome?

Ex. Grandparent, Aunt or Uncle, Caregiver, etc.

Your Age

Your Gender

Ex: Male, Female, Gender Neutral, Prefer not to say

Please ensure your parent or guardian signs this form before submitting. Thank you!

Would you like to partner with someone with Moebius syndrome?

How would you like to connect?

Which type of person would you most like to connect with?

Age Group preference for the person you'd like to be partnered with. *Note: If you are requesting career or education mentorship, you will be paired with an adult.

Do you have a preference on the gender of the person you'd like to connect with?

Profession, Specialty, or Background

What would make you feel like this program was helpful or successful for you?

Tell us a little more about yourself! Feel free to share fun facts, interests, or anything else that would help us find a great match for you.

Interests, hobbies, activities you enjoy, etc

Liability Disclaimer: The Moebius Syndrome Foundation (MSF) is not responsible for, and shall not be held liable for, any comments or advice shared through this program that a recipient may disagree with or find unsuitable. We cannot be held liable for such communications. MSF will try to partner people based on the information and preferences listed on the appliations to the best of their ability. However, it should be noted that MSF does not run background checks on any applicant, and depends on the integrity of applicants to be truthful and sincere in their intent.

Please use caution when sharing photos or any personal information with people you don't know well. Do not ever send money or sensitive information to anyone. If something doesn't feel quite right, stop communications and contact MSF staff right away.

If anyone feels uncomfortable with the person they are speaking to at any time, they should stop communications immediately and notify the Moebius Syndrome Foundation.

Only adults ages 18+ may independantly complete and sign this form. Teens, ages 13-17 must have their parent or guardian complete and sign this form on their behalf.

Moebius Connections is not a substitute for therapy, medical, or legal advice.

Please note that MSF will strive to connect people as quickly as possible, however, depending on the number and variety of appllcations received, it might take some time for us to find a potential match. MSF will contact you through email when there is an update.

You may contact MSF by emailing info@moebiussyndrome.org or calling +1 (844) 663-2487 ext. 700.

By signing below, I acknowledge that I have read and understand these conditions, and that the information I have listed is true to the best of my ability.

Signature

Parent Signature *Note: Teens ages 13-17 are required to have a parent or guardian sign on their behalf.

Date

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