JOIN OUR COMMUNITY

PATIENT/PARENT FORM. For CAH patients who have children with CAH. If you do not fit in this category, please find the appropriate form by going back to the Join Our Community page on our website.

First Name *

Last Name *

Suffix

Address 1 *

Address 2

City *

State/Province *

Zip *

Country *

Zip Code/Postal Code

MOBILE PHONE NUMBER (if you do not have one, enter N/A and add a house or work phone below): *

Phone

Phone Type

Email *

Email 2

P1. Do you, the person completing this registration form, have CAH? *

P2: CAH Type *

P3a: Date of Birth, MONTH *

P3b: Date of Birth, DAY *

P3: Year Born *

P4: Gender *

P5: Hospital, clinic or practice where you currently receive care. *

P6: How did you learn about CARES? *

Doctor
Hospital
Other healthcare professional
Friend
Family member
Other
Social Media Post

P6a: Please provide us with the name of the doctor, hospital, healthcare professional, friend, etc who referred you to CARES. *

P6b: If a doctor or hospital, please provide us with location, address info: *

P6c - If you heard about CARES via a website OR social media, please tell us where & what website or social media platform and post. *

P7: I am the parent of a child (or children) with CAH *

Yes
No

If you answered "no" to the above question, please join with the Patient Only form, or other form by using the JOIN links above.

THE FOLLOWING QUESTIONS REQUIRE AN ANSWER. IF THEY DO NOT APPLY TO YOU, PLEASE ENTER "N/A"

Are you married? *

What is the CAH status of your spouse? *

If married, please give your spouse's name *

What is your spouse's date of birth? _ _/_ _/_ _ _ _ *

Please list the names, CAH status, and date of birth of any other person/s in your household (other than spouse or children) *

PLEASE ANSWER THE FOLLOWING QUESTIONS TO GIVE US ADDITIONAL, HELPFUL INFORMATION. If they do not apply, enter "N/A"

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

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

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

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

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+

Would you like to receive news & announcements from CARES Foundation, Inc? *

Timeout Warning

JOIN OUR COMMUNITY