AGSAA Contact Registry Consent Form

By completing this opt-in form, you expressly consent to the Aicardi-Goutières Syndrome (AGS) Advocacy Association (AGSAA) collecting, processing, and storing your personal data in accordance with the General Data Protection Regulation (GDPR) and applicable laws. This consent is limited to the policies of the AGS Contact Registry. Your data will be securely stored and not shared for marketing.

You may withdraw consent at any time by contacting AGSAA.
For more details, see our Privacy Policy.
Email *
What is your full name? *
I have read and understand the purpose of the AGS Contact Registry *
I have read and understand the AGS Contact Registry privacy policy *

I authorize the AGSAA to collect and retain personal data about me for the following 12 months, adhering to the constraints outlined by the policies of the AGS Contact Registry
 *
I grant permission to the AGSAA to gather and maintain personal data concerning the specified dependents for the following 12 months, in accordance with the limitations set forth by the policies of the AGS Contact Registry
 *
Please list the full names of each dependent and their date of birth.
A copy of your responses will be emailed to .
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