Cerebral Palsy Connection Email Database Registration Form 
Individuals with CP - (version 4.5)

RED text:   You will not be able to submit the form in these are not filed in.
BLUE text: explains what information is be asked and how it will be used.

General Information
Only your first name and first letter of your last name will be displayed unless you check mark the display box in the left column to display your last name. Your Location will only be displayed on the database if you specify it to be in the DISPLAY section.
First Name
Last Name (See DISPLAY Section for more info)
Age/Gender
Email Address
NOTE: It is strongly recommended that you have a special email address for email lists and discussion groups rather then give out your personal home email to the public domain. Please put your full email address. I have had several people only put part of their address, particularly those on AOL or MSN. If you do not put your full address I have no way to contact you about the error and your name will not be put on the database.
Email Address (retype)
Where are you located?
Web page address
(please put FULL address)

 

 

Cerebral Palsy Information
This information will be used to let other members of the database know the type of CP you or your child has. Often it help another person or parents of a child with CP to be able to communicate with others in similar situations.
Class of Cerebral Palsy
Type of Cerebral Palsy
Spastic Mixed
Anthetoid Unknown
Ataxic
Other (if Class or Type not listed)
What Treatments have you tried?
Or what treatments are you wanting to try?

 

 

Communication Preferences
CPC supports ICQ, AOL, and MSN instant messengers. If you do not have any of these program, you may click on links to visit their web page. Up to three email addresses can appear on the database. If you provide more then one you can select which addresses will appear on the web page in the DISPLAY section.
Who do you want to communicate with?
Other Parents Same Age Group
Same type of CP No Preference
CP in General
How do you want to communicate with other people visiting the list?
ICQ
AOL
MSN
2nd Email

3rd Email

 

 

Display Preferences (REQUIRED)
This section lets CPC know what information you provided above that we are allowed to put on the web page. Any additional information you provide but do not authorize CPC to display on the site will be kept strictly confidential. 
Please let CPC know what information you want to display on the database for others to see? Check Mark means that information will be displayed on in the database automatically.

 

CHECK HERE if you only want those options with a Check Mark to be displayed on the page and disregard all other check boxes in this section.

 

NOTE: 1st email will be used in the database unless you say otherwise by check marking the last two options at the bottom of this section.

Check Mark Your First Name
Your Last Name
Age

 

Check Mark Type of CP Other CP (if provided)
Check Mark Class of CP

 

Check Mark Email Address ICQ
Location AOL
Website address MSN
2nd Email 3rd Email
Display 2nd email and DO NOT display 1st email
Display 3rd email and DO NOT display 1st email

 

 

Special Information
This can be anything you want to say and can be as long as you would like. CPC would ask that you supply something here as we do not know you personally and cannot speak for you.
What information would you like other members of the database to know about you or your child?

 

 

 

Comments/Suggestions
Comments are optional. CPC may decode to use your comment on its "Comments About CPC" web page. CPC values any information you can provide for improving anything about CPC. We are hear to serve the disability community.
Do you have any comments or suggestions about Cerebral Palsy Connection or how to improve it? Do you have any information or research you would like CPC to provide you with in the future?

 

 

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