Families
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Athletes & Teams
Want to make a difference doing what you do every day?
Make an Impact
Medical Resources & Referrals
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First Name *
Last Name *
Age * —Please choose an option—5678910111213141516
Diagnosis * —Please choose an option—Blood DisorderCancerCerebral PalsyConnective Tissue DisorderCystic FibrosisEpilepsyGI ConditionGenetic DisorderHeart ConditionImmune DysfunctionKidney DiseaseLung DiseaseMuscular DystrophyNeurologic DisorderNeuromuscular DiseaseSpina BifidaTransplantOther
Diagnosis Details Maximum 255 characters
Phone *
Email *
Preferred Language * —Please choose an option—EnglishSpanishMandarinCantoneseTagalogVietnameseArabicFrenchKoreanRussianGermanHaitian CreoleHindiPortugueseItalianPolishUrduYiddishJapanesePersianGreekASLPrefer not to answer
Do you want to include someone else? —Please choose an option—Yes, add a second Parent/GuardianNo
Street Address *
City *
State * —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code *
American Indian or Alaskan NativeAsianBlack or African AmericanLatinoNative Hawaiian or other Pacific IslanderWhiteOther
Household Income * —Please choose an option—$0 - $24,999$25,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000 - $149,999$150,000 - $199,999More than $200,000Prefer not to answer
How Did You Hear About Us * —Please choose an option—CampSchoolPatient Advocacy OrgCommunity OrganizationHospitalOutpatient Treatment CenterHomecare AgencyCurrent or Former Team IMPACT ParticipantSocial/News MediaOther
Camp * —Please choose an option—Camp 1Camp 2Other
Other Camp *
School * —Please choose an option—School 1School 2Other
Other School *
Patient Advocacy Org * —Please choose an option—Org 1Org 2Other
Other Patient Advocacy Org *
Community Organization * —Please choose an option—Org 1Org 2Other
Other Community Organization *
Hospital * —Please choose an option—hospital 1hospital 2Other
Other Hospital *
Outpatient Treatment Center * —Please choose an option—outpatient 1outpatient 2Other
Other Outpatient Treatment Center *
Homecare Agency * —Please choose an option—agency 1agency 2Other
Other Homecare Agency *
Social/News * —Please choose an option—FacebookInstagramTwitterYouTubeTikTokNewspaperTVOnline articleOther
Other Social/News *
Other *
Additional Comments
Nombre *
Apellido *
Edad * —Elija una opción—5678910111213141516
Diagnóstico * —Elija una opción—Trastorno sanguíneoCáncerParálisis cerebralTrastorno del tejido conectivoFibrosis quísticaEpilepsiaEnfermedad gastrointestinalTrastorno genéticoCardiopatíaInmunodeficienciaEnfermedad renalEnfermedad pulmonarDistrofia muscularTrastorno neurológicoEnfermedad neuromuscularEspina bífidaTrasplanteOtro
Detalles del diagnóstico Máximo de 255 caracteres
Teléfono *
Correo electrónico *
Idioma preferido * —Elija una opción—inglésespañolmandaríncantonésTagaloVietnamitaÁrabefrancéscoreanorusoalemáncriollo haitianohindiportuguésitalianopolacourduyiddishJaponésPersaGriegoASLPrefiero no contestar
¿Desea incluir a otra persona? —Elija una opción—Sí, agregar un segundo padre/madre o tutorNo
Dirección física *
Ciudad *
Estado * —Elija una opción—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Código postal *
Nativo estadounidense o nativo de AlaskaAsiáticoNegro o afroamericanoLatinoNativo hawaiano o de otras islas del PacíficoBlancoOtro
Ingresos del grupo familiar * —Elija una opción—$0 - $24,999$25,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000 - $149,999$150,000 - $199,999Más de $200,000Prefiero no responder
¿Cómo se enteró de nosotros? * —Elija una opción—CampamentoEscuelaOrganización de defensa del pacienteOrganización comunitariaHospitalCentro de tratamiento ambulatorioAgencia de atención domiciliariaParticipante actual o exparticipante de Team IMPACTRedes sociales o medios de comunicaciónOtro
Camp * —Please choose an option—Camp 1Camp 2Otro
School * —Please choose an option—School 1School 2Otro
Patient Advocacy Org * —Please choose an option—Org 1Org 2Otro
Community Organization * —Please choose an option—Org 1Org 2Otro
Hospital * —Please choose an option—hospital 1hospital 2Otro
Outpatient Treatment Center * —Please choose an option—outpatient 1outpatient 2Otro
Homecare Agency * —Please choose an option—agency 1agency 2Otro
Social/Noticias * —Elija una opción—FacebookInstagramTwitterYouTubeTikTokPeriódicoTVArtículo en líneaOtro
Otras redes sociales/noticias *
Otro *
Comentarios adicionales
