Contact Registry

Step 1 of 8

12%

I agree and acknowledge that I am authorized to provide the following information about myself, my family and the person(s) with AS listed hereafter. I also understand and agree that the ASF may contact me to provide information about Angelman syndrome, future research studies and trials and activities and programs offered by the ASF.

Agreement*

I Agree

I Do Not Agree

Please carefully read the statement above. You must agree to the statement to be able to proceed with completing the contact registry.

Name*

First Last

Email*

Phone*

Address*

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

Gender*

Male

Female

This step is optional.

Spouse / Partner Name

First Last

Spouse / Partner Email

Spouse / Partner Phone

Spouse / Partner Address

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

Spouse / Partner Gender

Male

Female

Contact Me*

Would you like to be contacted by a family member of someone with Angelman syndrome who can answer questions and direct you to information and resources?

Yes

I have already been contacted

How would you prefer to be contacted?*

Phone call

Text

Message me on social

Other

Phone

Provide the email address, phone number, social channel & profile name or other details about your preference.*

In addition to receiving the ASF newsletter via email, would you like to be added to our texting list to receive important reminders and news?*

We send approximately 10 texts a year.

Yes

Number to receive texts

Messaging & data rates may apply.

Newly Diagnosed*

Are you completing this form, because your child has recently received an Angelman syndrome diagnosis and you would like to receive information from the ASF?

Yes

Become a local contact in your area

Would you like to become a local contact for the ASF? Local contacts are knowledgeable and experienced with Angelman syndrome and are willing to have other families contact you about your person with AS, your family and your experiences.

Local Contact

Yes

My spouse/partner would like to become a local contact for the ASF. Local contacts are knowledgeable and experienced with Angelman syndrome and are willing to have other families contact you about your person with AS, your family and your experiences.

Spouse/partner would like to become a local contact

Yes

By agreeing to be a local contact for the Angelman Syndrome Foundation (ASF) I understand and agree that the following information will be provided to other AS families who may contact me directly: Name City and State Phone Number Email Address Age of Individual with AS Gender of Individual with AS Genotype of Individual with AS

Agreement*

Yes, I understand that by agreeing to be a local contact for the Angelman Syndrome Foundation (ASF) the above information will be released to other AS families.

Your relation to individual with AS*

Parent/Legal Guardian

Care Provider

Sibling

Aunt/Uncle

Cousin

Therapist

Medical Professional

Teacher

Other

Individual with AS

Person Name*

First Last

Date of Birth*

Month

Day

Year

Gender*

Male

Female

Genotype

Date of Diagnosis*

Add another person with AS?

Yes

Person with AS #2

Person Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Genotype

Add another person with AS?

Yes

Person with AS #3

Person Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Genotype

Add another person with AS?

Yes

Person with AS #4

Person Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Genotype

Add another person with AS?

Yes

Person with AS #5

Person Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Genotype

Add another person with AS?

Yes

Person with AS #6

Person Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Genotype

Add another person with AS?

Yes

Person with AS #7

Person Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Genotype

Are there siblings?*

Yes

Sibling

Sibling Name*

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Add new sibling?

Yes

Sibling #2

Sibling Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Add new sibling?

Yes

Sibling #3

Sibling Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Add new sibling?

Yes

Sibling #4

Sibling Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Add new sibling?

Yes

Sibling #5

Sibling Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Name

This field is for validation purposes and should be left unchanged.

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