ACD Association: "Searching for answers...hoping for a cure."

If you would like to register with our organization, please fill in the form below and then click the button at the bottom. If you would prefer, print out this page from your browser, fill it in and send it to:

The information that you provide will not be published on this website and will not be made available to any other party without seeking your written permission first.

Please enter your information below


Family name:
First names:
Address:
Telephone number:
E-mail:
* Children:
* Please include date of birth for all children and also a date of death for those children who were diagnosed with ACD. Please enter all dates in the format Day/Month/Year.
** The treatment your child received:
** Please list names of doctors & institutions as well as specific treatments such as ECMO, nitric oxide, etc.
Other abnormalities your child had:
May we share this information with:
Other families:	Yes No
Physicians/Researchers:	Yes No
Do you have any limitations that you wish to impose on the information shared?
Security Code:

When you have completed entering all the information above, please submit your registration by clicking on the "Submit" button below.

Please note: you will not be registered with our organization until you click the button below.