FARF Registration

Who is filling out this form? Check one or the other Parent, guardian, or primary caregiver to individual with FA
Adult individual with FA

First Name

Last Name

Phone Number

Email

Street Address

Street Address 2

City

State

Zip

Country

Your preferred pronoun Select She/Her He/Him They/Them I prefer not to say let me type

Preferred Pronoun

Primary language

Prefer to be contacted in this language

Additional information about the person with FA (minor or adult):

First Name

Last Name

Date of Birth

Assigned sex at birth Select Male Female Intersex Prefer Not To Say

Date of Diagnosis

History of cancer diagnosis?

Has the person with FA had a stem cell transplant

Identify as Select American Indian or Alaska Native Asian or Asian American Black or African American Hispanic, Latino, or Spanish origin Middle Eastern or North African Native Hawaiian or Pacific Islander White Another race or ethnicity not listed above (Type Below) Prefer not to answer

Specific Ethnic Identity Please provide your specific race or ethnic identity in the space below.

Demographic information on race and ethnicity is collected in order to ensure that we are providing services that are accessible to and inclusive and representative of the entire FA community. This data will be used to identify gaps in services and support those who may be underserved. It will be housed in a secure database with your contact profile and will be used for internal purposes only.

May FARF refer other families to you? Select Yes, any time Yes, if FARF notifies me first No

Join our mailing list? for newsletters and meeting announcements Select Yes No

Join our Facebook family support group? Select Yes No

Other Info Is there anything else you'd like us to know about you or your family?

Confidentiality Statement: Information collected on this registration form will be protected and stored in a secure contact database. Information will only be accessible by FARF staff with clearance to access the information for communication and internal purposes only. This information will be stored indefinitely, unless requested otherwise. You may request to have your contact profile information removed from the contact database at any time by submitting a request to info@fanconi.org

Informed consent: By completing this registration form, you agree that you have read and understood the confidentiality statement and purpose of the registration form, and voluntarily agree to register for Fanconi Anemia Research Fund, Family Services.