The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

yHbgwo3LHkhTpUbUgsKPWZWdq67s6YI9zyKRvmNSWTV2qtLVnKoAjmTkH6SXL9cdbdt5vCJeU2PiL

Kids at Heart Registration Form

I give permission to Children's Healthcare of Atlanta to send Heart Center newsletters, meeting and event notices, and other activities sponsored by the Heart Center at Children's Healthcare of Atlanta.

Children's does not share your personal information and you can opt out of any mailing at any time.

Child's Cardiac Diagnosis

* must provide value

Aortic Stenosis (AS)

Atrial Septal Defect (ASD)

Coarctation of the Aorta (COA)

Complete Atrioventricular Canal (CAVC)

Hypoplastic Left Heart Syndrome (HLHS)

Pulmonary Stenosis (PS)

Pulmonary Atresia (PA)

Tetralogy of Fallot (TOF)

Total Anomalous Pulmonary Venous Connection (TAPVC)

Transplant recipient

Transposition of the Great Arteries (TGA)

Ventricular Septal Defect (VSD)

Down syndrome

22 Q11.2 deletion (DiGeorge syndrome)

Turner syndrome

Noonan syndrome

Marfan syndrome

CHARGE syndrome

Cardiomyopathy

Hypertension

Truncus arteriosus

Congestive heart failure

Long QT

Other

Not sure

Today's Date

M-D-Y

Parent Last Name

* must provide value

Parent First Name

* must provide value

Parent Email Address

* must provide value

Alternate Email Address

Please confirm that you have typed in your correct email address above. You will be emailed additional information about our program upon completion of this registration form. If your email address is not correct you will not receive the information or our newsletter.

* must provide value

I have double checked that I have typed in a correct email address

Best daytime phone number

* must provide value

Address Line 1

* must provide value

Address Line 2

City

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State

* must provide value

Zip Code

* must provide value

County

* must provide value

Other county please specify

What side of Atlanta are you commuting from?

How far away do you live from Atlanta?

30 miles or less

More than 30 miles

More than 60 miles

More than 100 miles

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Your Heart Child's First Name

* must provide value

Your Heart Child's Last Name

* must provide value

The name your child goes by (if other than first name)

Date of Birth Date

* must provide value

M-D-Y

Age

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Gender

* must provide value

M F Unknown

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Other Diagnosis (please specify)

Does your heart child have any brothers or sisters?

Yes No

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First Sibling
(first name, last name)

First sibling date of birth

M-D-Y

First sibling gender

M F Unknown

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Add another sibling

Yes No

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second sibling
(first name, last name)

second sibling date of birth

M-D-Y

second sibling gender

M F Unknown

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Add another sibling

Yes No

reset

Third Sibling
(first name, last name)

Third sibling date of birth

M-D-Y

Third sibling gender

M F Unknown

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Add another sibling

Yes No

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Fourth sibling
(first name, last name)

Fourth sibling date of birth

M-D-Y

Fourth sibling gender

M F Unknown

reset

Add another sibling

Yes No

reset

Fifth Sibling
(first name, last name)

Fifth Sibling date of birth

M-D-Y

Fifth Sibling gender

M F Unknown

reset

Add another sibling

Yes No

reset

Sixth Sibling
(first name, last name)

Sixth Sibling date of birth

M-D-Y

Sixth Sibling gender

M F Unknown

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Add additional sibling(s)

Yes No

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Please write in the name(s) and birthdate(s) for any additional siblings. We love large families! Our apologies for the limited spaces on this form.

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Would you like to join our Private Kids at Heart Facebook Group? In our Facebook group heart parents have the opportunity to talk with one another, you can also use this group to find out about all Kids at Heart events and opportunities as well as other Children's Healthcare of Atlanta information. After completion of this form you will be sent a link to join the group. ALL of our information is posted in this group and MANY ways to connect are in this group. Please click the link in the email to join if you are interested.

* must provide value

I will check my inbox for an email with additional information about Kids at Heart

Do you have any comments or questions? Comment here or reach us by emailing kidsatheart@choa.org!

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