Resource Family Consent Form

National Organization for Disorder of the Corpus Callosum Family Partnership Program

The National Organization for Disorders of the Corpus Callosum (NODCC) Family Partnership Program maintains a database of families and adult individuals with a disorder of the corpus callosum (DCC) who volunteer to provide information and support to other families and individuals dealing with DCC .These resource families are not professionals, and they do not serve as representatives of the NODCC.

If you would like to be a volunteer Resource Family, please complete the form below.

My signature gives permission to only share my name, email address, phone number, city and state, with other families in the NODCC Family Partnership Program. The gender and year of birth of person with a DCC will also be included if provided. I understand my participation is voluntary, and I may request my information provided below be removed from the NODCC Family Partnership Resource Family database at any time.

Name(Required)

First Last

Date(Required)

Name

First Last

Date

Address

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

Email(Required)

Enter Email Confirm Email

Phone

Relationship to Individual with DCC:

Individual with DCC's name (optional):

Individual with DCC's Birth Year:

Gender:

Male

Female

Type of DCC:

Complete ACC

Partial ACC

Hypoplasia (thin) DCC

Dysgenesis of CC

Please list additional diagnosis:

Is it okay to list information above?

Yes

Type of resource information you would like to share:

Comments

28526

Resource Family Consent Form

National Organization for Disorder of the Corpus Callosum Family Partnership Program

Resource Family Consent Form

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