SUPPORT NETWORK DIRECTORY UPDATE FORM Please use this form to submit any changes for an existing listing on the Support Network Directory. TYPE OF CHANGEPlease indicate who or what this change is related to and if it is an update or a removal of a listing. The could be a change in contact information, a change in leadership role, or a change in a support group name or area contact geographically information. THIS CHANGE IS FOR: A Support Group Leader An Area Contact Leader Support Group Leader is changing to an Area Contact Leader Area Contact Leader is changing to a Support Group Leader The name of a Support Group Geographical location for an Area Contact Leader Other UPDATE OR REMOVE INFORMATION? Update Remove COMMENTS ABOUT THESE CHANGES INFORMATION TO BE UPDATEDRequired: Name and email of the person the change is related to is required. For updates, complete the fields that need to be changed. For removals, complete the name and email. Name* First Last Email* PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country UPDATE | Name of a Support GroupIf you would like to change the way a support group name is listed, please indicate below: UPDATE | Geographical Location for an Area Contact LeaderIf you would like to change the geographical location for your listing, please indicate below. Some examples include a broad geographical location, for example, San Antonio, TX, greater Pittsburgh, or eastern Dallas suburbs. UPDATE | Other PERSON SUBMITTING THE CHANGE*If you are submitting this change on behalf of someone, please indicate your name and email below so we may contact you with any questions. Self Other (please list name and email below) Name First Last Email Consent* I agree or have permission to make this change. I understand that any listing in the 'Support' pages of the dysphonia.org website may include the person's first and last name, their email address, and their general location (as provided above). Contact information may be removed at any time by Dysphonia International or on request by the person listed or their representative.CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ DOWNLOAD NSDA CONFLICT OF INTEREST POLICY DOWNLOAD NSDA CODE OF ETHICS POLICY
