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A-T Family Welcome Form

HomeAbout Ataxia-TelangiectasiaGet ConnectedA-T Family Welcome Form

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A-T PARENTS, LET’S KEEP IN TOUCH

It is 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.

"*" indicates required fields

1Caregiver Info

2Child Info

3Comments/Questions

Do you have a definite diagnosis of A-T?*

Yes

No

Doctors suspect A-T and are currently testing for it.

Yes

No

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 - Relation to Child*

Mother

Father

Guardian

Parent/Guardian 1 - Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian 1 - Email*

Parent/Guardian 1 - Confirm Email*

Parent/Guardian 1 - Cell Phone Number*

Parent/Guardian 2 - Name

First Last

Parent/Guardian 2 - Relation to Child

Mother

Father

Guardian

Parent/Guardian 2 - Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian 2 - Email

Parent/Guardian 2 - Confirm Email

Parent/Guardian 2 - Cell Phone Number

1. A-T Patient's Name*

First Middle Last

1. Birth Date*

MM slash DD slash YYYY

1. Gender*

Male

Female

Do you have another child with A-T to add?*

Yes

No

2. A-T Patient's Name

First Middle Last

2. Birth Date

MM slash DD slash YYYY

2. Gender

Male

Female

Do you have a third child with A-T to add?

Yes

No

3. A-T Patient's Name

First Middle Last

3. Birth Date

MM slash DD slash YYYY

3. Gender

Male

Female

Do you have a fourth child with A-T to add?

Yes

No

4. A-T Patient's Name

First Middle Last

4. Birth Date

MM slash DD slash YYYY

4. Gender

Male

Female

1. Sibling Name

First Last

1. Birth Date

MM slash DD slash YYYY

1. Gender

Male

Female

Is there a second sibling to add?

Yes

No

2. Sibling Name

First Last

2. Gender

Male

Female

2. Birth Date

MM slash DD slash YYYY

Is there a third sibling to add?

Yes

No

3. Sibling Name

First Last

3. Birth Date

MM slash DD slash YYYY

3. Gender

Male

Female

Is there a fourth sibling to add?

Yes

No

4. Sibling Name

First Last

4. Gender

Male

Female

4. Birth Date

MM slash DD slash YYYY

Is there a fifth sibling to add?

Yes

No

5. Sibling Name

First Last

5. Birth Date

MM slash DD slash YYYY

5. Gender

Male

Female

Do you have your child's ATM mutation (genetic) report?*

If you have the report and you are willing to share it with A-T researchers, please email a copy to our Executive Director, Jennifer Thornton at jennifer@atcp.org. Thank you!

Yes

No

I'm not sure

Best email address to contact you*

Best phone number to contact you*

Comments and/or questions

About Ataxia-Telangiectasia
Research
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- A-T CureTeam Race Weekends
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We’re available to answer your questions. We love the opportunity to see how we can help!

Email info@atcp.org CALL +1.954.481.6611

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6810 N. State Road 7, Suite 125 Coconut Creek, FL 33073 USA

+1.954.481.6611

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