Fill out the following form to join our registry
Parent/Guardian's Full Name
*
First Name
Last Name
Address
*
Street Address
City
State / Province
Postal / Zip Code
Country
*
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Email
*
example@example.com
Please tell us a little bit more about the person in your life who has been diagnosed with INAD.
Child's Full Name
*
First Name
Last Name
Sex
Male
Female
N/A
Birthdate
-
Month
-
Day
Year
Date
Age at Diagnosis
*
If they are no longer living, at what age did they pass away?
(required - if not applicable, please write N/A)
Your Relationship to this person
*
Please Select
Mother/Stepmother
Father/Stepfather
Foster Parent/Guardian
Grandparent
Sibling
Other
Has a Diagnosis been Confirmed?
*
Yes
No
What Form?
*
PLA2G6-Associated Neurodegeneration (PLAN)- Infantile neuroaxonal dystrophy (INAD)
PLA2G6-Associated Neurodegeneration (PLAN)- Atypical neuroaxonal dystrophy (ANAD)
PLA2G6-Associated Neurodegeneration (PLAN)- Dystonia-parkinsonism
Unsure
Variant
See below image for an example of where you can find this information
Other Comments
If you answer yes to any of the below, someone from the INADcure Foundation will reach out to you soon at the email address provided.
Please Check All That Apply
I would like to join the INADcure Private Facebook Group (family members only).
I would like to help raise awareness about INAD in my community.
I would like to volunteer with the INADcure Foundation.
I would like to learn about how I can help raise funds for the INADcure Foundation and support INAD research.
Is there any additional information that you would like to share with us at this time?
By filling in the form above, I am giving the INADcure Foundation permission to send me occasional emails and/or mailings. (required)
*
I Agree
Submit
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