CAH PATIENT

JOIN OUR COMMUNITY

for CAH Patients (only). If you are also the parent and/or relative of a CAH patient, then please choose one of the other forms on our JOIN OUR COMMUNITY page of our website.

First Name *

Last Name *

Suffix

Address 1 *

Address 2

City *

Country *

State/Province *

Zip *

Email *

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

Phone

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

*Proof of diagnosis may be required

P2: CAH Type *

P3: Year Born *

P3a: Date of Birth, MONTH *

P3b: Date of Birth, DAY *

P4: Gender *

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

THE FOLLOWING FIELDS/QUESTIONS REQUIRE AN ANSWER. PLEASE ENTER "N/A" FOR ANY THAT DO NOT APPLY TO YOU.

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

R1: Are you the relative (other than parent) or friend of a CAH-affected individual? *

IF YOU ANSWERED YES TO THE QUESTION P7 then you should be using the Patient/Parent form. Link above.

Are you married? *

If married, please give your spouse's name *

What is the CAH status of your spouse? *

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

PLEASE CHECK "YES" BELOW if you would like to be contacted by a Support Group Leader in your area. Support Group Leaders are trained volunteers whose families are personally affected by CAH. They sometimes organize local speakers and events, and can offer CAH guidance.

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. *

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

WHEN THIS FORM IS SUBMITTED, you will become a member of the CARES community and have a CARES account. Please create a username and password for this account so that you can track all of your transactions with CARES, including Shop purchases, event registrations, ticket purchases, donations, etc. You will also be able to update your account contact & CAH information.

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