CAH PATIENT WITH CAH CHILDREN

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About your CAH Child/Children

Please enter all of the information required for each child with CAH. If you wish to enter all children (perhaps in the case of a carrier), you may, but please list CAH affected children first. If you have more than 3 CAH-affected children, use the "Additional Space" field below to provide that child's information. For these fields that do not apply, enter "N/A".

C1a: CHILD 1 NAME *

C1b: CAH TYPE *

C1c: Birthday __/__/____ *

C1d: GENDER *

C1: YEAR BORN *

C2a: CHILD 2 NAME *

C2b: CAH TYPE *

C2c: BIRTHDAY __/__/____ *

C2d: GENDER *

C2: YEAR BORN *

C3a: CHILD NAME *

C3b: CAH TYPE *

C3c: BIRTHDAY __/__/____ *

C3d: GENDER *

C3: YEAR BORN *

Additional space

C4: Hospital, clinic or practice where your child/children receive/s care. *

C5: Child's/Children's Doctor/s *

Your message

As outlined in our privacy policy, CARES Foundation will not release your information to anyone without your permission.

When this form is submitted you will become a member of the CARES community and will have the opportunity to create a username and password for your account. We urge you to do so to be able to keep track of all your CARES transactions, including shop purchases, event registrations, tickets, donations, etc. You will also be able to update your account information and contact info.

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About your CAH Child/Children