DOC16 Membership Form

Join the Disorders of Chromosome 16 Foundation

Please Note: The following form is for a diagnosis of MOSAIC TRISOMY 16 only. As of March, 2013 the DOC16 Foundation is focusing solely on Mosaic Trisomy 16. For information regarding other chromosome 16 disorders, please contact mt16coordinator@gmail.com. Thank you.

Name:
Email Address:
Phone:
Address:
City (Required only for demographic purposes):
State (Required only for demographic purposes):
Zip Code:
Child's Name:
Child's Date of Birth or Estimated Due Date:
Diagnosis (At this time we are only working with diagnoses of Mosaic Trisomy 16).
How was the diagnosis made?	CVS but no Amniocentesis CVS and Positive Amniocentesis CVS and Negative Amniocentesis Amniocentesis Only Postnatally (skin biopsy, etc.) Other
If you are still pregnant at this time, how many weeks?
Have there been any pregnancy complications for mother or baby so far?
If the baby has already been born, at what gestational age did delivery occur (in weeks)?
What was the child's birth height & weight?
Have there been any health or developmental issues?
Tell us your story (whatever you'd like to share about your family's experience with MT16).
You may use our story and/or photos on the website, in newsletters, promotional brochures, etc.	Yes No
Would you like to have a role in the foundation?	Board of Directors Website Newsletter Peer Support Fundraising Other