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Joining the CARES Community: Account Information

Account Registration

First Name *

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Last Name *

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How did you learn about CARES? *

Doctor

Hospital

Other healthcare professional

Friend

Family member

Other

Social Media Post

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Email Address *

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Phone Number *

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Address Line 1 *

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Address Line 2

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City *

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State/Province *

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Zip/Postal Code *

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Country *

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Account Type: *

Patients

CAH Parents/Family

Parents of more than one CAH child

Relative of CAH patient/family

Medical Professionals

Donors/Supporters

Board of Trustees

CAREing Society

Support Group Leaders

CCC Staff

Medical & Scientific Advisory Board

Industry Professional

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We are submitting as a Company/Business

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Company Name

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Please provide us with the name of the doctor, hospital, healthcare professional, friend, etc who referred you to CARES:

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If a doctor or hospital, please provide us with location, address info:

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Person Completing Form: Information

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Do you, the person completing this registration form, have CAH? *

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CAH Type *

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Hospital, clinic or practice where you currently receive care?

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Gender *

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Date of Birth: MONTH *

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Date of Birth: DAY *

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Date of Birth: YEAR *

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Relatives of Affected Individuals

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Are you the relative (other than parent) or friend of a CAH-affected individual?

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How are you and the CAH-affected individual related: I am the individual's ________?

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Affected Relative/Friend: NAME (First, Last):

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Affected Child/Children: Information

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I am the parent of a child (or children) with CAH *

Yes

No

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Child 1: NAME *

Please type 'N/A' if not applicable

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Child 1: CAH TYPE *

Please select 'Unaffected' if not applicable

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Child 1: GENDER *

Please select 'Prefer not to say' if not applicable

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Child 1: YEAR BORN *

Please type 'N/A' if not applicable

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Child 1: Birthday __/__/____

Please type 'N/A' if not applicable

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Child 2: NAME *

Please type 'N/A' if not applicable

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Child 2: CAH TYPE *

Please select 'Unaffected' if not applicable

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Child 2: GENDER *

Please select 'Prefer not to say' if not applicable

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Child 2: YEAR BORN *

Please type 'N/A' if not applicable

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Child 2: BIRTHDAY __/__/____

Please type 'N/A' if not applicable

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Child 3: NAME *

Please type 'N/A' if not applicable

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Child 3: CAH TYPE *

Please select 'Unaffected' if not applicable

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Child 3: GENDER *

Please select 'Prefer not to say' if not applicable

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Child 3: YEAR BORN *

Please type 'N/A' if not applicable

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Child 3: BIRTHDAY __/__/____

Please type 'N/A' if not applicable

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Hospital, clinic or practice where your CHILD/CHILDREN receive/s care:

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CHILD/CHILDREN'S Doctor/s:

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Medical Professionals: Information

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Are you a medical professional? *

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Profession Type (please check all that apply):

N/A

Adrenal Surgeon

Adult Endocrinologist

Adult Endocrinologist/Internist

Adult & Pediatric Endocrinolog

Adult Urologist

Adult Urologist & Surgeon

Assistant Clinical Prof.

Assistant Prof. of Pedicatrics

Behavioral Health Specialist

Biochemist

Child Psychiatrist

Child Psychologist

Clinician

Dermatologist

DuoCort

Electrologist

EMS

Endocrinology

Endocrinology and Metabolism

Endocrinologist

Endocrinologist - Pediatric & Adult

Endocrinology Nurse

Ethicist

Family Practice

Family Practice Physician

General Medicine

Genetic Counselor

Geneticist

Hematologist

Hospital Administrator

Internal Medicine

Internist

Internist/Endocrinologist

Internist/Endocrinologist

Midwife

Neonatologist

Neuroendocrinologist

Neurologist

Newborn Sceening Director/Facilitator

Newborn Screening Research

Nurse (LPN)

Nurse - RN

Nurse (RN)

Nurse Practitioner

School Nurse - Public School

School Nurse - Private School

Nutritionist

OB/GYN

OB/GYN & Genetics

OB/GYN - Pediatric & Adolescent

OB/GYN-Reproductive Endo

PARAMEDIC

Patient Advocate

Pediatric Endocrinologist

Pediatric Endocrinology

Pediatric Endocrinology Fellow

Pediatric Nurse Practitioner

Pediatric Surgeon

Pediatric Urologist

Pediatrician

Pharmacist

Professor

Psychiatrist

Psychoendocrinologist

Psychologist

Public Health Professional.

Radiology

Radiologist

Registered Nurse

Reproductive Endocrinologist

Reproductive Endo.

Research

Scientist

Social Worker

Surgeon

Urogynecologist

Urology

Urologist

Writer

Other

Unknown

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Medical Professionals: Do you currently treat CAH patients?

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Medical Professionals: Are you interested in CAH research and/or treatments?

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Medical Professionals: Are you an EMS professional?

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Medical Professionals: Please give us your hospital affliliation, name and address (unless listed as primary address above)

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Medical Professionals: Please give us your practice name and address (unless listed as primary address above)

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Medical Professionals: Your Assistant/s Name/s:

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Medical Professionals: Assistant/s Email/s and Phone number/s:

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Medical Professionals: Are you a newborn screening professional?

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Misc.

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Would you like to be contacted by a Support Group Leader in your area?

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If you are interested in becoming a member of one of our Facebook Secret Support Group/s, please indicate that/those group/s below. You may choose more than one.

NOT INTERESTED

3 Beta Women

11 Beta

17 Hydroxylase

Bereavement

CAH Athletes

CAH Partners/Spouses

CARES Support Group Leaders

Classic CAH Women

Men with CAH

Men and Dads with sons with CAH

NCAH Women Support Group

Newborn Support Group

Parents of Kids with CAH

Parents of Kids with NCAH

Parents of Teens/Young Adults

Parents of Twins with CAH

Surgery Support Group

Teens with CAH

Teens/Young Adults Support Group

Women 50+

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Are there any topics that you would like to see covered in an upcoming newsletter or conference?

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Are you interested in volunteering? Please check all that apply.

Graphic design for CARES materials

Help at the CARES office (northern NJ)

Help at CARES event

Help recruit financial sponsors

Not interested

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Would you be interested in contributing an article to the CARES Foundation newsletter? If so, what topic?

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Additional Comments:

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or

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