Join Us!

Thank you for your interest in becoming a member of our international network! We are delighted that you have decided to join our community.

Your tax-deductible donation will support our web site, online support groups and discussion forums, CHD Awareness Day efforts, newsletter, and services to organizations and support groups throughout the world.

Once we receive your completed form, we will send you either an email message or postcard that will serve as your receipt. We will include information about how to submit your member page for the Portrait Gallery section of our site, and an invitation to join our online support groups.

For residents of the United States, a portion of the annual membership is tax-deductible:

Type	Annual Dues	Tax Deduction
Individual/Family	$ 20	$ 15
Donor	$ 50	$ 45
Sponsor	$100	$ 95
Benefactor	$250	$ 245

Donations without membership, and memorials or tributes are also welcome.  Click here for more information.

If you join online with a credit card using our secure system, you will have immediate access to our support groups, including the PDHeart list!

Renewals: if you are renewing your membership, please click here for the shorter membership renewal form.

 

Individual/Family Membership (click here for the Professional Membership Application) If you have any questions or need help with the medical information on your form, please feel free to contact us either by phone or email. Please use the Tab key to move between the fields.  Press the Enter key or click the Submit button when you are ready to submit the form. Please contact us if you would like to become a member and would like to request a waiver of the membership fees. We will promptly consider all requests for assistance.     I/We wish to join C.H.I.N. at this level: $  20 Individual / Family $  50 Donor $100 Sponsor $250 Benefactor Other: $   If you are a sponsored member, please select Other and enter 0 for the amount       Please tell us about yourself... We take the privacy of our members very seriously, and will not share the information that you submit below with anyone without your explicit prior permission. Please click here to see our complete privacy policy.  (Another window will open so you will not lose your place).     First Name     Last Name     Mailing Address     City     State/Province     Zip/Postal Code     Country         Daytime Phone     Evening Phone         Please provide your email address below or enter "None" if you don't have an email address.  We will use this address to contact you, and this is the address that will be authorized to subscribe to our members-only support and information lists.  Please double-check your entry to make sure it is correct.     Email Address         Family member with CHD Self Spouse Child Other Date of Birth: Month              Day Year (YYYY)     Name     Deceased Date: Month              Day Year (YYYY)         Second Family member with CHD (if applicable) Self Spouse Child Other Date of Birth: Month              Day Year (YYYY)     Name     Deceased Date: Month              Day Year (YYYY)     (Please use the comments box at the bottom of this form to tell us if you have more than two family members with CHD)         Your occupation  (optional)     Spouse/Partner's occupation  (optional)         Do you participate in a local support group? No Yes: Group Name and City         Defect/Syndrome List     Please check all that apply to your family.  If you do not see your family's CHD in the list, please tell us in the comments box.     Atrial Septal Defect (ASD) Aortic Valve Regurgitation Aortic Valve Stenosis Aortopulmonary Window (AP window) Anomalous Left Coronary Artery (ALCAPA) Coarctation of the Aorta Complete A-V Canal (CAVC) Congenitally Corrected Transposition Cor Triatriatum Double Outlet Right Ventricle Ebstein's Anomaly Hemi Truncus Interrupted Aortic Arch Mitral Valve Regurgitation or Stenosis Patent Ductus Arteriosus (PDA) Patent Foramen Ovale (PFO) Pulmonary Stenosis (PS) Shone syndrome Sub-Aortic Stenosis (sub AS) Tetralogy of Fallot (TOF) TAPVR Transposition of the Great Arteries Truncus Arteriosus Vascular Ring Ventricular Septal Defect (VSD)     Various forms of Single Ventricle (ultimately the Fontan operation, usually with prior states such as the Stage-1 Norwood Procedure, shunt, bi-directional Glenn or hemi-Fontan)     Double-Inlet Left Ventricle Heterotaxy Hypoplastic Left Heart Syndrome (HLHS) Hypoplastic Right Ventricle Pulmonary Atresia Tricuspid Atresia Single Ventricle     Other Cardiac-Associated Conditions     Cardiomyopathy Complete Congenital Heart Block Dextrocardia DiGeorge syndrome Down syndrome Eisenmenger Syndrome Hypertension (high blood pressure) Kawasaki Disease Noonan Syndrome Prolonged QTc Syndrome Protein-Losing Enteropathy (PLE) Pulmonary Hypertension Pulmonary Vein Stenosis Rheumatic Fever Situs Inversus Stroke Supraventricular Tachycardia (SVT) Turner Syndrome Velocardiofacial Syndrome (VCFS)       Treatments     Balloon Angioplasty Coil Embolization Defibrillator Intravascular Stent Pacemaker Radio Frequency Ablation Surgery Transplant Valve replacement          Suggestions and Comments (Optional) (Comments can also be emailed to mb@tchin.org)           Summary     Your contact and personal information will be kept strictly confidential, and will not be shared with anyone without your express written or electronic permission. If you wish to participate in a local networking system with other C.H.I.N. members in your area, please check the consent below.     I hereby authorize C.H.I.N. to release my name and email address to other members in my state for purposes of informal interaction, support and information sharing, or event planning.  I understand I can revoke this permission at any time. Please keep my information private.     Once you submit this form, you will be taken to a confirmation page, where you will be given the option to contribute securely online with a credit card, or by mail. Thank you again for your support!              Please report problems with this form to <sysadmin@tchin.org>

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Disclaimer: The contents of this site are presented for informational purposes only, and should not be substituted for professional advice. Always consult your (child's) physicians with your questions and concerns. Created and maintained by Mona Barmash and Uwe Baemayr for The Congenital Heart Information Network. Exempt organization under Section 501(c)3 Copyright ©1996 - 2008 C.H.I.N. all rights reserved TX4-390-685