Patient Family Enrollment Form

The Cockayne Syndrome Foundation is committed to protecting the privacy of individuals associated with our organization. We adhere strictly to a privacy code that ensures personal information provided to us remains confidential and is not shared with third-party organizations without explicit consent

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Patient Family Enrollment Form

Please provide the following information:

Name(s) of Patient Caregiver

Name(s) of child(ren) Diagnosed with Cockayne Syndrome/Trichothiodystrophy

Diagnosis/Mutation

Severity Level

Type 1 (Moderate)

Type 2 (Severe)

Type 3 (Mild)

Unknown

Age of child/children affected

Phone

Address

May we contact you via email or phone? If yes, which would you prefer?

Our current goal is to provide supplies needed for daily symptom management. This section is available for you to provide recommendations/preferences of products/supplies that are beneficial to your child(ren) so we may better serve families.

Does your child/children have any favorite toys, games, interests, hobbies? Do you have any suggestions for activities that might be fun/helpful for you and your child to better enjoy each day?

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