Name *

First Name

Last Name

Phone

(###)

###

####

Have you or a family member lived within a 3.5-mile radius of the W.L. Gore & Associates Cherry Hill Facility? *

Facility located at 2401 Singerly Rd, Elkton, MD 21921

Yes

No

Have you or another resident at that address been diagnosed with any of the following conditions? *

Kidney cancer

Testicular cancer

Endometrial cancer

Uterine cancer

Breast cancer

Prostate cancer

Ulcerative colitis

Thyroid disease

Type 2 diabetes

None of these

Please select if you or another resident at that address have experienced any of the following injuries or health conditions. *

Pregnancy-induced hypertension

Pregnancy-induced pre-eclampsia

Extreme developmental delays

Diagnosed high cholesterol

Liver toxicity damage

Miscarriage

Fertility problems

Early onset puberty

Vaccine resistance

Other condition, explain below

No diagnosis or injury