Family Supports - KCNQ2 Cure Alliance

Relationship to patient:*

Your Name:*

First Last

Do you live within the US?*

Yes
No

Your Information*

Address Line 1 City State ZIP Code

Your Information*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Email Address*

Enter Email Confirm Email

Patient Information:*

Patient First Name

Patient Gender:*

No Selection
Female
Male
Prefer not to answer

Birth Year

Diagnosis*

My child's variant is

Race*

Help us better understand the racial diversity of our patient population

American Indian / Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiians or Other Pacific Islander
White

How did you find us?*

Email response*

You will receive an email in a few hours from (community.support@kcnq2cure.org) as one of our group moderators will respond to your application. Please check your SPAM folder. A response to this email is REQUIRED to be approved for the KCNQ2 Parent Group.

I have read the above statement

Comment / Questions

Would you like to receive emails form us?*

Yes
No

I would like to receive the KCNQ2 Newsletter by email.

Consent*

I verify that the information provided is accurate to the best of my knowledge.

I verify that the information provided is accurate to the best of my knowledge. I understand that providing false or inaccurate information may result in my dismissal from the KCNQ2 support group.

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Supports & Resources

KCNQ2 Family Supports and Resources

KCNQ2 Caregiver Support Group

Parent Support Group

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