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Contact Registry
KdVS Individual
*
First Name
Last Name
KdVS Individual Email
*
If your KdVS individual does not have an email address, please enter the Primary Caregiver’s email address.
Verify Email
*
KdVS Individual Address (if different from caregiver)
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
KdVS Individual Birthdate
*
(mm/dd/yyyy)
KdVS Individual Gender
*
select one
Female
Male
Prefer not to answer
Mutation or Deletion?
*
select one
Mutation
Deletion
Unsure
Caregiver Name
*
First Name
Last Name
Caregiver Email
*
Verify Email
*
Caregiver Phone
Caregiver Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Additional Caregiver Name
First Name
Last Name
Additional Caregiver Email
Verify Email
Additional Caregiver Phone
Share with other KdVS Families?
*
select one
Yes
No
Share with KdVS Researchers?
*
select one
Yes
No