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Please fill out the following information:
Name(s) of Parent/Caregiver
Name(s) of Child(ren) Diagnosed with Cockayne Syndrome
Age(s) of Child(ren) Diagnosed with Cockayne Syndrome
Cockayne Syndrome (CSA/ERCC8)
Cockayne Syndrome (CSB/ERCC6)
Cockayne syndrome and Trichothiodystrophy (TTD)
Other (fill in below)
If Other, please fill in below:
Type 1 (Moderate)
Type 2 (Severe)
Type 3 (Mild)
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?
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