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MiCleft Gallery of Smiles
Membership Profile Request Form
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Visitors are very interested in seeing who is actively participating in the network.
Adding your profile/photos is the first step in making family connections!


Adding your profile is simple and can be done in two short steps!
1. Submit the "Gallery of Smiles" content form below.
2. Attach photos in a separate email to:
Teresa@MiCleft.org or Admin@MiCleft.org.

Gallery profiles usually include one of each:
before or newborn/infant photo
after, post-surgical or recent photo

Uploaded photos do not need to be perfect - We will make any necessary adjustments
Manipulated photos tend to pixel, send originals when possible.

*We make every attempt to add new profiles in an expeditious manner,
however, ask that you allow up to 48 hours for profile upload.
Upload confirmations will be sent to the email provided in this gallery form.

Your Full Name: *
Street Address: *
City State and Zip: *
Contact Phone: *
E-mail Address: *
Website URL:
Patient first name: *
Patient DOB: *
Name of surgical hospital/physician: *
Choose One: *
Other conditions:
MiCleft has my permission to publish: *First names, city and photos
and email address
and website URL
and phone number
Short paragraph/content: *

Verification Code:
Enter Verification Code: *

* Required
 

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Terms/Disclaimer                                                    Updated 2/16/2008                                                    Testimonial/Grati tude