Lottie's Light Foundation Registration Form

Register with Lottie's Light Foundation
Contact information
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Sign me up for the Lottie's Light newsletter

Yes please
Include my Spouse/Partner

YesNo
- Spouse/Partner Name
  
  First NameLast Name
- Spouse/Partner Email
  example@example.com
- Spouse/Partner Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Mailing Address
- Address
  
  Street Address
  
  2 Line Address
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Are you the Parent/Legal Guardian of CerTra Individual?*
  
  YesNo
- CerTra Individual's Information
- CerTra Individual Name
  
  First NameLast Name
- Gender
  
  MaleFemale
- Date of Birth
  
  MonthDayYear
  DOB
- Approximate Date of CerTra Diagnosis
  
  MonthDayYear
  Approximate Date Diagnosed
- Living/Deceased
  
  LivingDeceased
- Genetic Information
  
  A genetics report is one of the first steps toward effective research for our families. At this time Lottie's Light Foundation is not collecting reports; however, these reports are invaluable to have on hand for our HIPPA compliant partners in advance research.
- I have a copy of this person's genetics report.
  
  YesI need help accessing the genetic report
- Media
- Media
  
  Yes, I'd like to send in photos/videos of our family to help advocate for our CerTra children!No thank you
- Volunteer with Lottie's Light Foundation
- Interested in volunteering with Lottie's Light Foundation?
  
  Yes! Absolutely!Kinda... I have a lot on my plate but might like to do something small!No thank you
- Fundraising
- Interested in fundraising to illuminate a cure for CerTra syndrome?
  
  Yes, I would love to learn more about planning an event!Yes, I would love to do something with minimal effort, like an online share!Yes, I have experience in fundraising and have other ideas to share!
- Research
- Research
  
  Yes, I would like to know more about CerTra Syndrome studies currently enrollingYes, I would like to learn more about how my family can contribute to important research tools to push the development of treatments forward
- Please verify that you are human*
- Should be Empty:

Register with Lottie's Light Foundation

Contact information

Mailing Address

CerTra Individual's Information

Genetic Information

Media

Volunteer with Lottie's Light Foundation

Fundraising

Research