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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?*
Doctors suspect A-T and are currently testing for it.
Parent/Guardian 1 Name*
Parent/Guardian 1 - Relation to Child*
Parent/Guardian 1 - Address*
Parent/Guardian 2 - Name
Parent/Guardian 2 - Relation to Child
Parent/Guardian 2 - Address (if different from above)
1. A-T Patient's Name*
MM slash DD slash YYYY
1. Gender*
Do you have another child with A-T to add?*
2. A-T Patient's Name
MM slash DD slash YYYY
2. Gender
Do you have a third child with A-T to add?
3. A-T Patient's Name
MM slash DD slash YYYY
3. Gender
Do you have a fourth child with A-T to add?
4. A-T Patient's Name
MM slash DD slash YYYY
4. Gender
1. Sibling Name
MM slash DD slash YYYY
1. Gender
Is there a second sibling to add?
2. Sibling Name
2. Gender
MM slash DD slash YYYY
Is there a third sibling to add?
3. Sibling Name
MM slash DD slash YYYY
3. Gender
Is there a fourth sibling to add?
4. Sibling Name
4. Gender
MM slash DD slash YYYY
Is there a fifth sibling to add?
5. Sibling Name
MM slash DD slash YYYY
5. Gender
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!
  • About Ataxia-Telangiectasia
    • Learn about A-T
      • What is A-T?
      • How is A-T Inherited?
      • Diagnosing A-T – A Note to Physicians
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      • Additional Clinical Information
        • Chapter 1: Ataxia-Telangiectasia Overview
        • Chapter 2: The Gene (A-T) and its Gene Product (ATM)
        • Chapter 3: Inheritance
        • Chapter 4: Neurology Problems
        • Chapter 5: Immunodeficiency
        • Chapter 6: General Care During Infections
        • Chapter 7: Feeding and Swallowing
        • Chapter 8: Cancer and the Risk of X-Ray Exposure
        • Chapter 9: The Eye and Vision
        • Chapter 10: General Principles of Rehabilitation
        • Chapter 11: Mobility and Gross Motor Abilities – Physical Therapy
        • Chapter 12: Activities of Daily Living and Fine Motor Abilities – OT Recommendations
        • Chapter 13: School Learning and Social/Emotional Adjustment
        • Chapter 14: Speech and Language
        • Chapter 15: Assistive Technology for Written Communication
        • Chapter 16: Lung Disease and Ataxia-Telangiectasia
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Email info@atcp.org CALL +1.954.481.6611

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