Join Us!

Please complete the form below if you would like to be added to one of our lists, or if you would like a member of our group to contact you.

*First Name:

*Last or Family Name:

*Phone # (555-555-5555):

*Home Address:

*Email Address (Please state in the form: my.name@service.node):

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I would like to be added to: (select all that apply)

Electronic Discussion List Monthly Meeting Mailing Annual Mailing for the Party

Would you like a family with a child with similar heart challenges to contact you? yes No

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My "heart" child is a Boy Girl who is years old.

This child has what kinds of heart problems?

Septal Defects Atrial Septal Defect (ASD) Atrioventricular (AV) Canal Ventricular Septal Defect (VSD)	Cyanotic Heart Defects Hypoplastic left heart syndrome Tetralogy of Fallot Transposition of the great arteries Truncus arteriosus
Blood Vessel Defects Aortic stenosis Coarctation of the aorta Pulmonary stenosis	Other Heart Defects Patent ductus arteriosus (PDA) Other