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2025 Angelman Syndrome Foundation.
All rights reserved.
3015 E. New York Street, Suite A2 #285
Aurora, IL 60504
(800) 432-6435
info@angelman.org

Contact Registry

The ASF has been supporting families for over 30 years while funding the research that has made the biggest strides toward a cure for Angelman syndrome.

The best way to stay up to date on resources, programs, events and research is to complete our contact registry form.

If your address or any information has changed, complete the form so we can update our records.
You will receive emails about programs, research updates and events.
If you have recently received a diagnosis, you will receive a packet of information about how and where to begin your journey.

Agreement

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.

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

First Name

Last Name

Your Email

Phone Number

Street Address

Street Address 2

City

State / Province / Region

ZIP / Postal Code

Country

Gender

Male Female

Ethnicity/Race

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Other

Please specify

Spouse / Partner Information

Add Spouse / Partner information?

Yes No

First Name

Last Name

Email

Phone Number

Street Address

Street Address 2

City

ZIP / Postal Code

Country

State / Province / Region

Gender

Male Female

Ethnicity/Race

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Other

Please specify

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 No I have already been contacted

How would you prefer to be contacted?

Email Phone call Text Message me on social Other

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 receive texts from ASF with important reminders and news?
We send approximately 10 texts a year.

Yes No

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 No

Your relation to individual with AS

Parent/Legal Guardian Care Provider Sibling Aunt/Uncle Cousin Therapist Medical Professional Teacher Other

Individual with AS

First Name

Last Name

Date of Birth

Gender

Male Female

Ethnicity/Race

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Other

Please specify

Genotype

Date of Diagnosis

Add another person with AS?

Yes

Individual with AS #2

First Name

Last Name

Date of Birth

Date of Diagnosis

Gender

Male Female

Ethnicity/Race

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Other

Please specify

Genotype

Add another person with AS?

Yes

Individual with AS #3

First Name

Last Name

Date of Birth

Date of Diagnosis

Gender

Male Female

Ethnicity/Race

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Other

Please specify

Genotype

Add another person with AS?

Yes

Individual with AS #4

First Name

Last Name

Date of Birth

Date of Diagnosis

Gender

Male Female

Ethnicity/Race

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Other

Please specify

Genotype

Contact Registry

The ASF has been supporting families for over 30 years while funding the research that has made the biggest strides toward a cure for Angelman syndrome. The best way to stay up to date on resources, programs, events and research is to complete our contact registry form.

If your address or any information has changed, complete the form so we can update our records.

You will receive emails about programs, research updates and events. If you have recently received a diagnosis, you will receive a packet of information about how and where to begin your journey.

Are there siblings?

Yes No

Sibling

First Name

Last Name

Date of Birth

Gender

Male Female

Add new Sibling?

Yes

Sibling #2

First Name

Last Name

Date of Birth

Gender

Male Female

Add new Sibling?

Yes

Sibling #3

First Name

Last Name

Date of Birth

Gender

Male Female

Add new Sibling?

Yes

Sibling #4

First Name

Last Name

Date of Birth

Gender

Male Female

Thank you for completing the ASF Contact Registry.

If you indicated that your child was recently diagnosed with Angelman syndrome, you will be receiving information at the email you entered on the form. Next, please consider enrolling in LADDER. The LADDER database creates a higher level of understanding of AS which increases the potential for future discoveries that will lead to clinical trials and treatments. Learn more and enroll in LADDER. If you have any questions or need help with anything, feel free to call our office at 800-432-6435 or email info@angelman.org.

With kind regards, Angelman Syndrome Foundation

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The mission of Angelman Syndrome Foundation is to advance the awareness and treatment of Angelman syndrome through education and information, research and support for individuals with Angelman syndrome, their families and other concerned parties. We exist to give all of them a reason to smile, with the ultimate goal of finding a cure.

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2025 Angelman Syndrome Foundation. All rights reserved.
3015 E. New York Street, Suite A2 #285, Aurora, IL 60504
(800) 432-6435
info@angelman.org

2025 Angelman Syndrome Foundation.
All rights reserved.
3015 E. New York Street, Suite A2 #285
Aurora, IL 60504
(800) 432-6435
info@angelman.org