Wufoo

Sign-up

Yes! I want to take part in the Hands-Down-a-Thon to help myself to greater recovery from hair-pulling and skin-picking!

Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - (###) - ### ####
Email *

(please use same email on StopPulling.com or StopPicking.com for identification purposes. All your information will be kept strictly confidential between TLC and PsychTech Ltd.)
I will be signing up for *
StopPicking.com StopPulling.com
I agree: *
I will sign up for two months on StopPulling.com or StopPicking.com, at $30/month. My second month will be refunded to me upon completion of my Hands-Down-a-Thon in October 2008.
I agree: *
To create a fundraising page for TLC using firstgiving.com, email this page to friends and family so that they can sponsor me in my Hands-Down-a-Thon. I understand that all money raised will be sent directly to TLC, to support sufferers, educate the public, and train treatment providers.
Finally, *
I release Trichotillomania Learning Center, Inc from any and all liabilities that might occur due to my participation in the TLC Hands-Down-a-Thon.
I agree: *
I am at least 18 years old.
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