SCDF Adults with Sickle Cell Disease Support Group Registration Form

SCDF Adults with Sickle Cell Disease Support Group Registration Form
Para obtener el formulario en español, seleccione la opción ubicada en la esquina derecha de esta pantalla
Thank you for your interest in joining our sickle cell support group. This group is for people with sickle cell disease (SCD) and their caregivers. We meet regularly on Discord and have calls once a month to share our experience, learn from each other, and provide emotional support. We also will meet once a quarter in person to meet face to face!

California Residents Only!
Personal Information
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Email Address*
example@example.com
Mobile Number*
Preferred Method Of Contact*
Sickle Cell Information
Do you have SCD or are you a caregiver of someone with SCD?*

I have SCDI am a caregiver of someone with SCD
If you have SCD, what type do you have?*
If you don't know your SCD type, you can ask your doctor or check your medical records. Knowing your SCD type can help you understand your condition better and get the best treatment possible.
If you are a caregiver, what is your relationship to the person with SCD?*
How long have you or the person you care for been diagnosed with SCD?*
What are some challenges or difficulties that you face because of SCD?*
Support Group Information
What are your expectations or goals for joining the support group?*
What topics or issues would you like to discuss in the support group? *
Do you have any questions or concerns about the support group? If so please express below.
Thank you for completing the registration form. We will contact you soon with more details about the support group. We look forward to meeting you and welcoming you to our community.
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SCDF Adults with Sickle Cell Disease Support Group Registration Form

Personal Information

Sickle Cell Information

Support Group Information