Register as a Patient Family

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Name(s) of Parent/Caregiver

Name(s) of Child(ren) Diagnosed with Cockayne Syndrome

Age(s) of Child(ren) Diagnosed with Cockayne Syndrome

Address

Phone

Diagnosis/Mutation

If Other, please fill in below:

Severity Level

May we contact you by phone and/or email?

How many children are diagnosed with Cockayne Syndrome in your family?

How many children diagnosed with Cockayne syndrome are alive in your family?

What is your child or children's diagnosis date?

What are your social media handles? (Twitter, Instagram, Facebook, TikTok)

How can we support or assist you?

What is your primary language?

Register as aPatient Family