Contact Registry

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

No

I have already been contacted

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

Resources emails*

In addition to our email newsletter, would you like to receive a quarterly email about resources that are available for individuals and their families?

Yes

No

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

No

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

No

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.

Are there siblings?*

Yes

No

articles and announcements

Contact Registry

Become a local contact in your area

Individual with AS

Person with AS #2

Person with AS #3

Person with AS #4

Person with AS #5

Person with AS #6

Person with AS #7

Sibling

Sibling #2

Sibling #3

Sibling #4

Sibling #5