A-T Family Database Registration

A-T Family Database

It's important for A-T families to stay in touch with the A-T Children's Project for information about clinical studies, caregiver handbook updates, and more. Please fill out the form below and submit your information.

If you would like your child's picture included in our photo gallery, please email a picture to .

We have a definite diagnosis of A-T	Yes No

Doctors suspect A-T and are currently testing for it	Yes No

Mother's First Name
Mother's Last Name
Complete mailing address including street address, city, state (prov), zip code (postal code) and country
Home phone including area code
Cell phone including area code
Preferred email address
Confirm preferred email address

Father's First Name
Father's Last Name
Father's complete mailing address if different from the above
Home phone including area code
Cell phone including area code
Preferred email address
Confirm preferred email address

If child(ren) do not live with both parents, who is the primary cargiver?	Mother Father Other guardian
Guardian's first name
Guardian's Last Name
Guardian's relationship to A-T parent(s)
Guardian's complete mailing address including street address, city, state (prov), zip code (postal code) and country
Home phone including area code
Cell phone including area code
Preferred email address
Confirm email address

1. A-T patient's first, middle & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

2. A-T patient's first, middle & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

3. A-T patient's first, middle & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

4. A-T patient's first, middle & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

1. Sibling of A-T patient: first & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

2. Sibling of A-T patient: first & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

3. Sibling of A-T patient: first & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

4. Sibling of A-T patient: first & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

5. Sibling of A-T patient: first & last name
Gender	Female Male
Date of birth (month/day/year)
If deceased, date of death (month/day/year)

Have you been to the A-T Clinical Center at Johns Hopkins Hospital?	Yes No

If not, are you interested in going?	Yes No

Are you interested in connecting with other A-T families?	Yes No

May we share your information with researchers & doctors studying A-T?	Yes No

Are you interested in participating in clinical studies?	Yes No Maybe

Register for E-News Subscriptions	A-TCP Newsletter Research Updates Fundraising News Marathon/Races Alerts

The A-T Children's Project is funded by the grassroots efforts of families and friends. Are you interested in learning how you can get involved in fundraising?	Yes No	*

Best email address to contact you		*
Confirm best email address		*
Best phone number to contact you		*

Comments or questions

Click the submit button to send your information to the A-T Childen's Project

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A-T Family Database Registration

A-T Family Database

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