*Name of EB child/teen/adult/angel:

*Date of Birth: (you can just put the birth year if you'd like)

*Form of EB: (please be as specific as possible, if it's unknown you can just put unknown)

Location:

Parents Names:

Brief Life History:






Goals/Aspirations/Talents:






Likes/Dislikes:





Date of passing:

Cause of death:

Poem: (If there's a special poem you would like me to add I'd be happy to do so)






Favorite Memory:






*E-mail Address:



2nd E-mail Address: (if you would like to add another e-mail address please put it here along with the person's name it belongs to)



Homepage:

* signifies a required field
* Please choose one
If you're filling this out for an EB angel you can also fill out the following information, but it is not required
You can submit up to 3 photos by clicking HERE
My Bravenet Photo Album will open in a new window where you will see an option to "Upload New Photos". Click on that and then select how many photos you would like to upload. Click next and you can then pick which photos to upload, they must be in either JPEG, GIF or PNG format and the image file size can be no bigger than 150kb. Don't forget to put your e-mail, please use the same e-mail address you used in this form so I can tell which photos belong to you.
If this is for an EB Angel I will except more than 3 photos and will add anything else you'd like, just e-mail me and let me know.

WHEN YOU'RE DONE SUBMITTING PHOTOS DON'T FORGET TO COME BACK TO THIS PAGE AND HIT THE "SUBMIT" BUTTON BELOW TO SUBMIT YOUR FORM.

If you have problems uploading your photos you can also e-mail them to me at ebpatient@gmail.com
To make things easier, if you could put as the subject either
"EB Child" "EB Teen" "EB Adult" or "EB Angel" and their name it would be much appreciated, thanks!
I would prefer them to be in either GIF or JPEG format if possible. Zip files are ok also.

Hi there! Thank you for getting involved with my site. Below is the form to add either an EB Child, EB Teen, EB Adult or EB Angel to my site. A few fields are required but the rest are optional and you can submit as much or as little info as you'd like. Please keep in mind that whatever you submit will be posted on my site. Feel free to e-mail me if you need any help.
ebpatient@gmail.com
Submit an EB Child/Teen/Adult/Angel
EB Child (12 and under)
EB Teen (13-17)
EB Adult (18 & up)
EB Angel
check here if you would like your e-mail address displayed on my site
check here if you would like your web site address displayed on my site
Check here if you have or  will be submitting photos
check here if you would like your 2nd e-mail address displayed on my site