Registration Form

Completion of this form will add you to the IDEAS mailing database for our newsletters, conference announcements and special mailings. This mailing database is maintained by the IDEAS Board and is not shared with external organizations. If you provide permission to share your name, IDEAS will add your name to a listing of families affected by isodicentric or interstitial duplications, and related disorders of chromosome 15. This listing is provided only to our member families.

Your Name:

Spouse/Partner's Name:
Affected Child's Name:

Date of Birth:
Karyotype (ie. Genetic diagnosis):
When was the disorder diagnosed? Prenatally    At Birth    At age: 
   
Does your child have and autistic spectrum disorder? Yes      No
     If Yes, what is the diagnosis?
   
Does your child have a seizure disorder Yes      No
     If Yes, what Type(s)
   
Other secondary disabilities or conditions:
   
Siblings: Yes      No
     Comments about siblings:
Mailing Address:
Address Continued:
City:
State:
Zip/Postal Code:
Country:
Home Phone:
Email:
Languages spoken fluently
(other than English):
Please check the appropriate box(es)

Please add me to the IDEAS mailing database for newsletters and other announcements.

I give permission for IDEAS to release my contact information to other IDEAS families.

Please do not release the above information to anyone.

I would appreciate a follow up call.

I am a:

Parent

Grandparent

Professional

Other:

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