RELATIVE OF CAH PATIENT

JOIN OUR COMMUNITY - Relatives/Friends of CAH Patients

Please use this form if you are the immediate relative or friend of a CAH patient ONLY. If you are a If you need to join as a patient, parent, etc. then please return to our website and choose the correct category on our JOIN OUR COMMUNITY page.

First Name *

Last Name *

Suffix

Address 1 *

Address 2

City *

State/Province *

Zip Code/Postal Code *

Country *

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

Phone

Email *

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

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

Yes

No

If you answered "yes" to the question "P1", or "P7", please use the appropriate form by using the Form Links above.

THE FOLLOWING QUESTIONS (delineated by the letter "R") pertain to your relative only.

R1: Are you the relative/friend *

R2: How are you and the CAH-affected individual related: I am the individual's ________? *

R3a: RELATIVE/FRIEND'S NAME (First, Last) *

R3b: CAH TYPE *

R3d: GENDER *

R3c: BIRTHDAY__/__/____ *

R: YEAR BORN *

Please enter "N/A" if you cannot answer the following questions.

R4: Is this CAH-affected relative a member of your household? *

R4a: If you answered "No", please provide us with the relative's address: *

R4b: Relative's email address *

R4c: Relative's phone number (preferably mobile) *

Please complete the following helpful information.

P6: How did you learn about CARES? *

Doctor

Hospital

Other healthcare professional

Friend

Family member

Other

Social Media Post

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

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

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. *