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Membership Form
Full Name
Yes
No
Are you a Parent or Guardian?
Male
Female
Sex of Parent or Guardian
Yes
No
Are you a CHD survivor?
Yes
No
Would you like to receive mailings of our newsletter and other educational materials relating to CHD?
Mailing Address
City
State / Region of Residence
Zip Code
Country of Residence
E-mail Address
Phone Number
Child or Children's First Name
Child or Children's Last Name
Sex of the Child (Male, Female or Unknown)
Date of Birth or Expected Date of Birth
Date of Passing, if your Child is an Angel
HRHS Diagnosis (Ex. Tricuspid Atresia, PA / IVS, Pulmonary Stenosis, DILV, DOLV)
Date and Name of Surgeries Already Perfromed (mm/dd/yy)
Future Surgeries and Expected Date of Surgery
Hospital Name
Hospital Address (can be just City and State)
Surgeon's Name
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