Membership Application Form Name and Address Name:*FirstLast Address:* Street Address City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Home Phone:* Area Code - Phone Number E-mail: Work Phone: Area Code - Phone Number Cell Phone: Area Code - Phone Number Information about your Child/Individual with PWS Child's Ethnicity (check all that apply):*African AmericanAsianCaucasianHispanic/LatinoNative AmericanOther Relationship*Parent/GuardianSibilingGrandparentAunt or UncleFamily FriendResidential or Vocational Service ProviderSelf - I have PWSother Name of Individual with PWS*FirstLast Birth Date:*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Age: Date of Diagnosis:01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Gender:*MaleFemale Diagnosis Type:*DeletionUPDImprinting MutationTranslocationClinicalAcquired/TBIOtherUnknown/Unsure Regional Center Affiliation: Physician Name Hospital Affiliation:Additional Information Total Household Income (for grant writing purposes only):Less than $10,000$10,001 to $19,999$20,000 to $29,999$30,000 to $39,999$40,000 to $49,999$50,000 to $59,999$60,000 to $69,999$70,000 to $79,999$80,000 to $89,999$90,000 to $99,999$100,000 to $149,999$150,000 or more Your Occupation(s) or Areas of Interest or Expertise: Language(s) you speak in addition to English:Description of Committees Committee Work (I am interested in learning about these committees):FinanceFundraisingLegislative AffairsOversightsPublications (including Newsletter)ProgramPublic AwarenessResidential ServicesResearch Sharing List:You may share my name with other families for support and networking purposesPlease Keep my name confidential, available only to PWCF officialsI'm interested in joining a support group Are you a member of PWSA-USA?YesNoPlease send me PWSA-USA membership information Send Quarterly Newsletter:via Emailvial Mail to address above Electronic Signature:*Send a copy of this form to yourselfSubmitReset
