Please complete the following information and press "Submit Form" to transmit the information.  You will then be directed to a page where you can make your membership contribution using Visa, MasterCard, American Express or Discover.  If you'd like to mail this form with a personal check, please print this form and mail it along with your contribution of $35.00 to:

Please note: NUCDF takes your privacy very seriously.  We will not  release information to any outside party without your explicit written consent.

Name			Title
Department			Organization
Street Address			Address (con't)
City			State/Province
Zip Code/Postal Code			Country
Home Phone			Work Phone
EMail
Professional Membership	Not Applicable Medical Doctor Nutritionist Teacher Organization Other		Family - Disorder	CPS NAGS OTC ASD ALD AG HHH
NUCDF is a volunteer non-profit organization dedicated to the identification, treatment, and cure of Urea Cycle Disorders. Membership benefits include our newsletter, research and treatment updates, networking program, our annual conference, information and educational resources, and the NUCDF national database. By sharing, caring, and supporting, our members can make a difference in each others lives.
Preference for Receiving Newsletter	Mail EMail		EMail address for Newsletter
Completing the following questionnaire is optional. However, it will assist us in understanding and supporting the needs of our urea cycle families and determining prevalence and outcome of the disorders.
Do you have a child that has been diagnosed with a Urea Cycle Disorder?				Yes No
If you answered 'Yes' to question A, please proceed to question B. If you answered 'No', why have you decided to join the NUCDF?
B. Please complete the following information regarding all of your children, including those not affected by UCDs:
Child #1	Male Female		Type of Disorder:	CPS NAGS OTC ASD ALD AG Age at Time of Diagnosis:
Is this child Living?	Yes No		Current Age:	Year of Birth:
Year of Death	Age at Death:			Cause of Death:
Child #2	Male Female		Type of Disorder:	CPS NAGS OTC ASD ALD AG Age at Time of Diagnosis:
Is this child Living?	Yes No		Current Age:	Year of Birth:
Year of Death	Age at Death:			Cause of Death:
Child #3	Male Female		Type of Disorder:	CPS NAGS OTC ASD ALD AG Age at Time of Diagnosis:
Is this child Living?	Yes No		Current Age:	Year of Birth:
Year of Death	Age at Death:			Cause of Death:
If you have been diagnosed with a urea cycle disorder:
Type of Disorder: CPS NAGS OTC ASD ALD AG			Age at Diagnosis: Current Age:
Our goal is to educate medical professionals and provide update information about new treatments, tests, etc. Please provide your physician's contact information to be included on the physician mailing list:
D. Name of treating geneticist/metabolic specialist:
Name			Title
Department			University/Hospital
Street Address			Address (con't)
City			State/Province
Zip/Postal Code			Country
Phone			Fax
EMail			Web Site
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NUCDF. Copyright (C) 2005 National Urea Cycle Disorder Foundation. All Rights Reserved.

Revised: 2/9/2006