C.H.I.N. Individual/Family Membership
(click here for
Professional Memberships)
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.
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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).
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Salutation
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First Name
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Middle Name or Initial
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(optional)
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Last Name
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Suffix |
Sr., Jr. M.D., D.O., etc. (optional)
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Mailing Address
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City
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State/Province
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Zip/Postal Code
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Country
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(please leave blank if USA)
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Daytime Phone
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(optional)
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Evening Phone
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(optional)
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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.
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Email Address
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Family member
with CHD |
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Date of Birth: Month
Day
Year (YYYY)
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Name
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Date: Month
Day
Year (YYYY)
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Second Family member
with CHD (if applicable) |
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Date of Birth: Month
Day
Year (YYYY)
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Name
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Date: Month
Day
Year (YYYY)
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(Please use the comments box at the bottom of
this form to tell us if you have more than two family members with CHD)
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Your occupation
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(optional)
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Spouse/Partner's
occupation
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(optional)
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Do you participate
in a local support
group?
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Please enter the name and
city/state/country (or leave blank if none)
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Defect/Syndrome List
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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.
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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)
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Other Cardiac-Associated Conditions
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Treatments
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Suggestions and Comments (Optional)
(Comments can also be emailed to
membership@tchin.org)
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Privacy Election
Your contact and personal information will be kept strictly confidential, and
will not be shared with anyone without your express permission.
If you wish to participate in a local networking system with other C.H.I.N.
members in your area, please select the consent below.
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Submit the Form
As an anti-spam measure, please type the two words below into the box and then
submit the form. If the words are hard to read, click the refresh button. Click
? for help.
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