Dear Friends:

Thank you for being in touch with us concerning the “bereavement group”.

As an organization, as much as we try to accomplish in our goals of support, education and research, unfortunately we lost friends for a variety of reasons, mostly from complications.

We share your grief, but feel that our mission would be incomplete if we did not address the needs of those spouses and families who have lost dear ones.

With your signed permission (see below), we will create a network of other people who have also suffered a loss connected to GBS. You may be in touch with one another.Of course, these names are to be shared only with those on the list. We take pride in keeping a strict measure of confidentiality with all names.

I give permission to have my name listed, to be shared only with other "Campy" patients.

Name:___________________________________________________________ Age: __________


Address: _______________________________________________________________________


City: _____________________________________________State:__________ Zip: ___________


Phone: (__________) ______________________ - ______________________________________


Email: __________________________________________________________________________


Signature: ________________________________________________________________________


Name and relationship of deceased: ____________________________________________________

Please mail or fax this form to the information below:

GBS/CIDP Foundation International - The Holly Building - 104 1/2 Forrest Ave. - Narberth, PA 19072
Phone: 610-667-0131 - Fax: 610-667-7036 - www.gbsfi.com - E-mail: info@gbsfi.com