Trisomy 18 - Trisomy 13 - SOFT - Edwards Syndrome

MEMBERSHIP JOIN/RENEW FORM

* Please fill in all required elements | Date format: mm/dd/yyyy

Parent Details

Parent Name(s)

*City:

*ZIP/Postal:

*E-mail Address:

*Street Address:

*State/Province:

*Country:

*Phone:

Child Details

Child Name

*Date of Birth:

Cause of Death:

*Affected Chromosome:

*Diagnosis:

Other (please explain):

*Sex:

Date of Death:

Other (Specify):

Translocation (Specify):

Child Health Information

Child Health Inquiries: Providing SOFT with information about your child's growth, immunizations and surgeries is optional. This data might be of help for other families or for medical studies concerning our children. We would appreciate your input.

Growth

How is (or was) your child fed?

Is (or was) your child able to self feed?

Birth weigh:

Birth Length:

Current date:

Current Weight:

Current Length:

If your child is no longer living please provide last known measurements at what approximate age :

Response

(lbs/oz)

(inches)

(lbs/oz)

(inches)

Immunizations

Is your child or, if no longer living, was your child up-to-date with your state recommended immunizations?

Is (or was) your child on a delayed immunization schedule?

Did you decline (refuse) any immunizations?

If 'Some' chosen please explain:

Did your child receive the Synagis series for prevention of RSV?

Does (or did) your child receive a seasonal flu vaccine every year?

If your child had any reactions to any vaccines/shots, please explain which immunization and reaction.

Response

Surgical Information

Surgical Information: SOFT receives frequent inquires about surgeries. If additional space is needed, use 'add surgery' button first to make as many lines as needed on web registration, then fill fields or send requested information on separate page, if filling out a paper form.

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SOFT Survey

How did you learn about SOFT?

Barb Van Herreweghe is the contact person for states that do not have a local chapter chair. Have you been in contact with Barb?

Have you been in contact with someone from your state or near-by state that is your state's local SOFT chapter chair?

Subscription Information

~ SUBSCRIPTION INFORMATION: U.S. = $25; All Other Countries = $35 in U.S. Funds ~
MULTIPLE YEAR SUBSCRIPTIONS ARE WELCOME!
We accept either VISA or MasterCard through PayPal

Membership Length:

Membership Typle:

Joey Watson Fund: This fund was established to help financially challenged families attend the annual SOFT Conference.
If you wish to donate to this fund, please add a donation to your membership fees.

Joey Watson Fund: (amount of donation)

PLEASE SEND THIS FORM AND PAYMENT TO:

SOFT Membership Committee, c/o Barb VanHerreweghe, 2982 South Union St., Rochester, NY 14624

We assume that your name may be shared with other SOFT members unless you specify otherwise.

FOR U.S. FAMILIES ONLY: We depend on subscriptions to support publishing and mailing costs, but if you cannot afford subscription and still wish to receive the newsletter, please call Barb VanHerreweghe at (800) 716-7638 for information about a LIMITED NUMBER of scholarships.