Registration Form

Welcome to the NFED! Registration in our First Connect program is free and entitles you to receive our newsletter, Enews Update, care provider referrals, and to network with other individuals in the NFED family. Please complete all areas of the form below. The NFED will contact you with helpful information and answer any questions you may have. Upon receipt of your completed form, we will send to you an extensive information packet on the ectodermal dysplasias and NFED services.

This form is secured by VeriSign	Registration Form Welcome to the NFED! Registration in our First Connect program is free and entitles you to receive our newsletter, Enews Update, care provider referrals, and to network with other individuals in the NFED family. Please complete all areas of the form below. The NFED will contact you with helpful information and answer any questions you may have. Upon receipt of your completed form, we will send to you an extensive information packet on the ectodermal dysplasias and NFED services.

First Name
Last Name
Street Address
Address (cont.)
City
State
Country
Zip Code
Phone Number
E-Mail Address

NFED Information
I am: (Check all that apply)	an individual affected by ectodermal dysplasia the parent of an individual affected by ectodermal dysplasia sibling of an individual affected by ectodermal dysplasia care provider social worker other

Individuals Affected By Ectodermal Dysplasia
First Name
Last Name
	Male Female
Birthdate

First Name
Last Name
	Male Female
Birthdate
Ectodermal Dysplasia Syndrome	Ankyloblepharon-ED-Clefting AEC (Hay-Wells Syndrome) Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC Syndrome) Focal Dermal Hypoplasia (Goltz Syndrome) Hidrotic Ectodermal Dysplasia (Clouston Syndrome) Hypohidrotic Ectodermal Dysplasias (HED) Incontinentia Pigmenti (IP) Rapp-Hodgkin’s Syndrome (RHS) Trichorhinophalangael (TRP Syndrome I) Witkop’s Tooth Nail Syndrome Other Unknown
First Connect Welcome Packet
As a registered member of the NFED, I’d like to receive my First Connect information packet via (choose one).	Email (PDF format) CD in the Mail (files are in pdf format) Print (via mail)
The EDucator Newsletter
As a registered member of the NFED, I’d like to receive The EDucator newsletter via:	Don’t send The EDucator. I will read/print it from the NFED Web site. Print (via mail)
I have a question about:
ENews Updates
As a registered member of the NFED, I’d like to receive E-news updates via email:	Yes. No
You may share my name with other people who are affected by ectodermal dysplasias and are looking to talk to someone in my area:	Yes No