Registration form

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Registration form

Section 1 and 2: Registration Form and Main Contact

Please complete your own details. If you aren't affected by a leukodystrophy, please select unaffected and leave details of diagnosis blank.

At the end of Section 2 you will be asked 'Do you want to add another family member?'

If you have an affected child or family member, click yes and continue filling in the next sections with their details.

Sections 3-11: Registration Form (Family Member)

Please complete details of any other family members in the further sections of the form

Any questions regarding the form, please contact info@alextlc.org

What is your email address? *

How did you find out about Alex TLC? *

Internet Search

Socials (Facebook/Twitter/Instagram/LinkedIn)

Referral from Inherited White Matter Disorders Service/Registry

Referral from health professional

Referral from another organisation

Referral from other family

Other:

If you were referred by a health professional or the Inherited White Matter Disorders Service/Registry, please can you let us know the name of the professional/doctor who referred you

Press next to begin form or follow the link below to view our privacy policy

https://www.alextlc.org/privacy-policy/

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