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GAND Family Intake Form
Helping Hands for GAND welcomes you to into the GAND community! Please help us to better connect our community and track the growing number of GAND cases worldwide by sharing a little about your family.
Please only submit this form if your child has been officially diagnosed with a pathological GATAD2B variant. If you have questions, please email us at info@GATAD2B.org.
* Indicates required question
Email
*
Your email
Full Name of Your Child with GAND (Please list all if more than 1 is diagnosed.)
*
Your answer
Your GAND Child(ren)'s Birth Month and Year
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Your answer
When was your child diagnosed with GAND? (Month & Year)
Your answer
Father's Full Name
Your answer
Father's Email
Your answer
Mother's Full Name
Your answer
Mother's Email
Your answer
Please provide the name(s), relationship(s), and email address(es) for any other adults who live with the child.
Your answer
Names of Siblings
Your answer
Where are you located? (city, state/province, & country)
*
Your answer
Sharing Your Location
Many GAND families are interested in knowing where other GAND families are generally located. We would like to provide a map to the GAND community with pins placed at the city level for each known case. (Otherwise, they tend to overlap in the same spot.) No names or other identifying information will be used on the map. Please select the "city" option below unless you would prefer one of the less specific options.
Do we have your permission to include your general location on a map of GAND cases to be shared with the GAND community?
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Yes, you may place a pin in my city.
Yes, you may place a pin in my state/province/county/region.
Yes, you may place a pin in my country.
No, please do not include any pin for our family.
Other:
Connecting Families
Many newly diagnosed families desire to make connections with GAND families living near them. We would like to facilitate these connections by sharing your email address with families requesting that information.
Do we have your permission to share the parents' email addresses provided above to fellow GAND families requesting contact information?
*
Yes
No
Other:
Is there any information about your child or family you would like to share with us? (e.g., type of genetic variant, specific challenges, etc.?)
Your answer
Thank You
We appreciate you taking the time to complete this form. If you have any questions about this form or any other matter, please email us at info@GATAD2B.org. Thanks and welcome to the GAND family!
A copy of your responses will be emailed to the address you provided.
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