BARE Support Application Form
This application helps us understand you and your child's journey with Biliary Atresia (BA) so we can connect you with the most effective support. We ask for some personal information about you and details about your child’s BA diagnosis. Your responses will remain confidential and are used solely to enhance your experience within our support group.
Applicant Information:
Describe Your Role
Please Select
Caregiver
Patient (18+ yrs old)
Full Name of Caregiver:
First Name
Last Name
Email:
example@example.com
Primary Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Prefer Not To Answer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer Not To Answer
Other
Primary Language Spoken At Home:
English
Spanish
Other
Marital Status (Current)
Single (never married)
Married
Domestic partnership / Civil union
Separated
Divorced
Widowed
Prefer not to answer
Highest Level of Education Completed:
Less than High School
High School Diploma or GED
Associate degree (AA, AS)
Bachelor’s degree (BA, BS)
Master’s degree (MA, MS, MBA, etc.)
Doctoral or professional degree (PhD, MD, JD, etc.)
Trade or vocational certification
Prefer not to answer
Employment Status
Employed full-time
Employed part-time
Self-employed
Unemployed and looking for work
Unemployed and not looking for work
Stay-at-home parent / full-time caregiver
On leave from work (e.g., medical, family, or personal leave)
Student
Retired
Prefer not to answer
Biliary Atresia Diagnosis Information
Biliary Atresia Diagnosis Date
-
Month
-
Day
Year
Date
Center Affiliation (At Time of Diagnosis)
Marital Status (At time of diagnosis)
Single (never married)
Married
Domestic partnership / Civil union
Separated
Divorced
Widowed
Prefer not to answer
Is your child transplanted?
*
YES
NO
If 'Yes," Please input your child's transplant date:
-
Month
-
Day
Year
Date
Current age of BA child?
Current Center Affiliation (If different from diagnosis)
Current age of all NON-BA Children:
Please Select Either "Yes" or "No" Below:
Do you have access to internet and Zoom?
YES
NO
Are you able to attend an hour session, once a week? (this will most likely be an evening session on a Sunday)
YES
NO
Can you commit to a 4 week session?
YES
NO
Have you previously attended any support group or counseling related to your childs diagnosis?
YES
NO
If not admitted for a current session, are you interested in being put on a waitlist for future sessions?
YES
NO
What are you hoping to gain from participating in this group?
Please rank your support systems 1 to 5. "1" being the most impactful and "5" being the least impactful
Immediate Family/Partner/Spouse
*
1
2
3
4
5
Extended Family & Friends
*
1
2
3
4
5
Medical Professionals
*
1
2
3
4
5
Online Community
*
1
2
3
4
5
Religious/Spiritual Support
*
1
2
3
4
5
N/A
Is there anything else you would like us to know when reviewing your application?
Contact In Case of Emergency
A person we can contact in the event of an emergency
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Terms & Conditions
By submitting this application, I acknowledge that the information I have provided is accurate to the best of my knowledge. I understand that participation in the BARE (Biliary Atresia Research & Education) caregiver support group is voluntary and intended solely for informational, emotional, and peer support purposes. This group does not provide medical advice, diagnosis, or treatment, and is not a substitute for professional medical care.I consent to the collection and secure storage of my personal information for the purpose of support group coordination and communication. BARE respects the confidentiality of all applicants and will not share personal information without explicit permission, except as required by law.By joining, I agree to participate respectfully and uphold the group’s values of empathy, privacy, and mutual support. BARE reserves the right to remove participants who violate community guidelines or engage in inappropriate conduct.
Signature of Applicant
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: