Membership form

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Lisa Schoyer USA
  Tammy Moore USA
  Leonie Bence   Australia

Anyone who has a connection to Costello syndrome can join for free.

What we Expect From Our Members:-

To share information
To help sustain this international support network. You can help by providing in-kind support or
fundraise.
To be responsible about using information.
To keep information confidential. Members are NOT to distribute information from our member's area, unless you have permission to do so.
To respect diversity. The ListServe is for the discussion of Costello syndrome, and day to day social topics which will help to build our community. Discussions about politics and religion may cause offence due to the different cultures of our members. We are an international organization, so what is acceptable in one country may not be acceptable in another.
To safeguard website content. All of the information on this web site is provided for the benefit of the Costello syndrome community. Itmust not be used for commercial gain or profit. However The contents of this website may be freely used for the purpose of education, and training, or any not for profit use which is of benefit to the Costello community.
To join, please complete the Join the Support Group Form below.
We also require you to fill in the Development Form.
Requests to join will be verified by phone and occasionally initial contact will be made via email. If you cannot be contacted, you will not be able to join the support ListServe. We must know that all members are who they say they are. This is to protect our membership from Spam.
You agree to the information submitted via this form being held by the International Costello Syndrome Support Group, and the Costello Syndrome Family network. In order to provide the best support we can to your family.

Join Our Support Group
Your Family Details
Email Address		Required
Mothers First Name		Required
Mothers last name		Required
Fathers First Name		Required
Fathers Last Name		Required
The CS Person's Name		Required
The CS persons Date of Birth
Mothers Age when the child was born
Fathers Age when the child was born
		CostelloKids is about the whole family. Could you please tell us about the other children in your family
Do you have any other children in your family		yes no
If the answer to the above question is yes. Could you please list the childrens names and birthdate's
Your Address
House Number
Address Line 1		Required
Address Line 2
City		Required
Zip / Post code		Required
Home Phone number		Required
Cell Phone Number
State/Province (US/Canada only)
Country
About the CS Diagnosis
The name of the doctor who diagnosed CS
Where was the diagnosis made
The address of the diagnosis Center
Genetic Testing
		A simple genetic test can be carried out to confirm the diagnosis of Costello Syndrome. It is important for this test to be done to aid diagnosis, treatments and therapy. If the diagnosis has not been confirmed by testing. Visit Genetests for more Information
Has a gene test been done to confirm the diagnosis		yes no
There are several Mutations in HRAS which are known to cause CS. If Known select the mutation ID from the list.
And Finally
Would you like to join our E-mail discussion list		yes no
In order to provide a better support service may we share your contact details with other support group members.		yes no
Please enter anything else you would like to tell us about yourself