STARS US

Materials Request

We thank you for your help in increasing the awareness of Syncope. Without your help, we would not be able to extend our reach throughout the country. You have made a difference.

It is important that we know what people are doing in their communities. Please let us know how you used the materials as we would like to share with our funders, Board of Trustees, volunteers, though your reports and stories. (Remember we are here to help you)

Personal Details

1. Name*
2. Address line 1*
3. Address line 2
4. Address line 3
5. City*
6. State*
7. Postcode/Zip*
8. Telephone
9. Email address*
10. Relationship to Sufferer
11. Sufferers Name
12. Sufferers Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
13. Male of Female Male / Female
14. Diagnosis made Yes / No
15. If Yes - please provide a brief description

Materials Requested

1. What do you plan to do with these materials?
2. Are you planning a fundraiser? Yes / No
   If yes please download the media kit for guidance.
3. STARS Introduction Brochure
   This Brochure is for the general public introducing STARS and the work we do.
   
   
4. STARS Awareness Poster
   These are great for schools, libraries, community centers, fundraisers.
   
   
5. STARS Educational Booklets
   These booklets explain specific syncope conditions.
   
   Syncope Vasovagal / Neurocardiogenic / Reflex Syncope Syncope and your Child (to include Reflex Anoxic Seizures) Blackouts Checklist
   To be given to medical professional, undiagnosed individuals.
6. How did you hear about STARS