Lottie's Light Foundation Registration Form

Register with Lottie's Light Foundation
Contact information
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Sign me up for the Lottie's Light newsletter

Yes please
Include my Spouse/Partner

YesNo

Spouse/Partner
Spouse/Partner Name

First NameLast Name
Spouse/Partner Email
example@example.com
Spouse/Partner Phone Number
Please enter a valid phone number.

Mailing Address
Mailing Address
Address

Street Address

2 Line Address

CityState / Province

Postal / Zip CodeCountry
Are you the Parent/Legal Guardian of CerTra Individual?*

YesNo

Media
Media
Media

Yes, I'd like to send in photos/videos of our family to help advocate for our CerTra children!No thank you

Volunteer with Lottie's Light Foundation
Volunteer with Lottie's Light Foundation
Interested in volunteering with Lottie's Light Foundation?

Yes! Absolutely!Kinda... I have a lot on my plate but might like to do something small!No thank you

Fundraising
Fundraising
Interested in fundraising to illuminate a cure for CerTra syndrome?

Yes, I would love to learn more about planning an event!Yes, I would love to do something with minimal effort, like an online share!Yes, I have experience in fundraising and have other ideas to share!

Research
Research
Research

Yes, I would like to know more about CerTra Syndrome studies currently enrollingYes, I would like to learn more about how my family can contribute to important research tools to push the development of treatments forward

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