Clone of COUNTING CASK

UK CASK Registry

Are you the parent or guardian of someone diagnosed with a CASK gene mutation in the UK or Ireland?
Please join our small and friendly UK and Irish group so you can:
- Receive your welcome family pack full of CASK goodies
- Be invited to our annual family meet up
- Find other families living near you
- Be invited to UK or worldwide studies and trials
This form is for caregivers of an individual (patient) with a CASK mutation only.

For families with more than one CASK case, please register separately for each patient.
Contact information
Full Name

First NameLast Name
Spouse or partner's name

First NameLast Name
Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Patient name

First NameLast Name
My CASK warrior is
Patient Date of birth

MonthDayYear
Date
Has the patient been given a named disorder?
What type of mutation does the patient have? (skip question if unknown or unsure)
Has a doctor told you that the mutation on the CASK gene is the reason for your child's problems?

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Confirmation
Should be Empty:

UK CASK Registry