Completion of this form will add you to the Dup15q Alliance mailing database for our newsletters, conference announcements and special mailings. This mailing database is maintained by the Dup15q Alliance Board and is not shared with external organizations. If you provide permission to share your name Dup15q Alliance will add your name to a listing of families affected by isodicentric or interstitial duplications, and related disorders of chromosome 15. This listing is provided only to our member families.
Member Registration Form
*Your Name:
Spouse's/Partner's Name:
*Affected Individual's Name:
*Affected Individual's Birth Date
Year
*Karyotype (ie. Genetic diagnosis):
When was the disorder diagnosed?
Does your child have and autism spectrum disorder?
If Yes, what is the diagnosis?
Does your child have a seizure disorder?
If Yes, what Type(s)
Other secondary disabilities or conditions:
Siblings:
Comments about siblings:
*Mailing Address:
Address Continued:
*City:
*State:
*Zip/Postal Code:
*Country:
Phone:
*Email:
Languages spoken fluently (other than English):
Please check the appropriate box(es):
*I am a:
*Image Verification:
81032
All information is kept confidential and is not released to ANYONE outside of Dup15q Alliance.
We do not sell our mailing list or provide names to any outside party, including researchers.
Giving permission to release your contact information to other Dup15q Alliance families is used for the following reasons: Sunshine Committee (receiving a birthday card), connecting with other local families and being included in our family directory which is distributed at conference.
*Gender
Dup15q Alliance, P.O. Box 674, Fayetteville, NY 13066 USA
855-dup-15qa info@dup15q.org
Policy Regarding Use of Dup15q Alliance Trademarks
The trademarks, logos, and service marks (“Marks”) displayed on this website, and related websites belonging to Dup15q Alliance, including the Dup15q Alliance logo, among others, are trademarks of the Dup15q Alliance, are the property of Dup15q Alliance, and are protected. Their uses are restricted to those programs and events sponsored by Dup15q Alliance, and Dup15q Alliance trademarks may not be used for personal financial gain. Use of the Marks is prohibited without the express written consent of Dup15q Alliance. Nothing contained on the Site should be construed as granting, by implication, estoppel, or otherwise, any license or right to use the Marks without the express written consent of Dup15q Alliance.
At times, Dup15q Alliance may grant limited-use licensing agreements to those individuals or groups who wish to help further the mission of Dup15q Alliance. Solely at the discretion of Dup15q Alliance, limited permission for use of Dup15q Alliance’s Marks may be granted for those projects which provide a substantial benefit to Dup15q Alliance or the chromosome 15q duplication syndrome community in general. For consideration, please submit, in writing, a letter of intent, which details how the Dup15q Alliance’s Marks will be used, the length of time they will be used, and the benefit of the project to Dup15q Alliance or the chromosome 15q duplication syndrome community to info@dup15q.org at least 45 days prior to launch.
Letters of intent may also be sent to: Dup15q Alliance, PO Box 674, Fayetteville, NY 13066, or send an e-mail to info@dup15q.org.
