Pre-Registration Form

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Science Needs You

Each year, more people than ever before are being diagnosed with disorders such as Autism Spectrum Disorder (ASD), Fragile X Syndrome (FXS), and other Neurodevelopmental Disorders.

Brain donation helps researchers study the brain. While tremendous progress is being made in biomedical research, there is so much more information that neuroscientists are working to discover. Breakthroughs in brain disorders depend on brain donations of human brain tissue after a donor has passed. It's important to know that many brains are needed from diverse populations and ages to help researchers investigate the causes of these neurodevelopmental disorders to develop more effective therapies for future generations.

Since one brain can provide tissue for dozens - sometimes hundreds - of neurological studies, an individual brain donation is a highly valuable gift that almost anyone can make for a huge impact.

Please complete the pre-registration form below and someone from the CENE team will contact you. Thank you!

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First Name: (exactly as it appears on the Birth Certificate, please no abbreviations) *

Middle Name: (exactly as it appears on the Birth Certificate, please no abbreviations) *

Last Name: (exactly as it appears on the Birth Certificate, please no abbreviations) *

Donor Street Address, City/Town, State, Zip code, Country of Birth *

Donor Phone Number *

Donor Alternate Phone Number *

Donor Email *

Donor Date of Birth: (MM/DD/YYYY) *

Donor Sex at Birth: *

Male

Female

Other

Gender Identity: (optional) *

Has the donor ever been diagnosed with a disorder affecting the brain? *

If yes to the question above, please specify the nature of the disease/disorder including at what age the symptoms became apparent.

Do you agree to receive the registration forms by email? *

Yes

If not, we will mail them to the address listed above. Let us know if you need accommodations for this.

其他：

Person Completing Form: *

Self (donor)

Legal Next of Kin (LNOK order of Hierarchy) 1. Legal Executor of Estate 2. Spouse 3. Adult Child 4. Parent 5. Adult Sibling 6. Adult Grandchild 7. Grandparent 8. Adult who exhibited special care and concern for the decedent 9. Adult who acts as a Guardian

Health Care Proxy

其他：

必填

If Person Completing Form is other than Self, please tell us your 1. name, 2. relationship to donor (if Registrant is a minor or incapacitated, whether you are the Legal Guardian) and an 3. email of where to send the registration packet.

Date Completed (MM/DD/YYY): *

YYYY

How were you made aware Of CENE?

Online Search

Patient or Disease Support Group

Clinician or Physician

Clinical Trial or Research Study

Family or Friend

Social Media

Option 7

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