Potentials Foundation

Your contact information:
Full name:	* required
Names of parents:	* required
Names of sibblings:
Email address:	* required
Street address:	* required
City:	* required
State, Province, or Region:	* required
Postal Code:	* required
Country:	* required
Telephone number:
Alternate phone number:
Add my contact info to the family directory:	Yes No
Additional information:
Diagnosis:	No Diagnosis MOPD I/III MOPD II Meier-Gorlin MPD Not Classified Russell-Silver Seckel Antley-Bixler Dubowitz Fanconi Bloom Other
If Other or Unknown please provide details:
Name of diagnosing physician and institution:	* required
Have you tested for gene mutations? If so do you have the results:
Please indicate any known chromosomal changes:
Date of birth:	* required
Birth weight:	* required pounds grams kilograms
Term:	* required less than 28 weeks 29-30 weeks 31-32 weeks 33-34 weeks 35-36 weeks 37-38 weeks full term
Length at birth:	* required inches centimeters
Head circumference at birth:	* required inches centimeters
Current weight:	* required pounds grams kilograms
Current height:	* required inches centimeters
Current head circumference:	* required inches centimeters
Wingspan: the measurement from fingertip to fingertip of outstretched arms:	* required inches centimeters
Wingspan measured by Doctor or Parent:	Doctor Parent
Amount of growth in the last 12 months:	* required inches centimeters
Best description of childhood activity level:	Low activity, inactive Average/typical High energy, hyperactive, limited attention span
Best description of your child's development:	Normal for age Slight developmental or learning delay Severe developmental or learning delay Severe delay caused by stroke
Your child's communication method:	Oral language Sign language No ability to speak or communicate after age 2
Vision issue requiring glasses:	Yes No Unsure
Hearing loss:	Yes No Unsure
Narrow airway resulting in a high pitched voice:	Yes No
Vascular stenosis, moyamoya or aneurysm:	Yes No Unsure
Type 2 diabetes:	Yes No Unsure
Elevated cholesterol or blood lipids:	Yes No
High blood pressure or kidney issues:	Yes No
Scoliosis or thoracic kyphosis:	Yes No
Forearm Mesomelia (disproportionately shortened):	Yes No
Coxa Vara or similar hip joint dislocation issues:	Yes No
Elbow dislocation or range of motion issues:	Yes No
Hyperflexive ligaments:	Yes No
Missing Patella:	Yes No
Early Feeding Issues:	Yes No
Early Respiratory Issues:	Yes No
Delayed bone age:	Yes No Unsure
Small teeth, reduced enamal, shallow roots:	Yes No
Fine sparse hair:	Yes No
Darkened skin pigmentation spots:	Yes No
Shoe size:	<5 Toddler 5-5.5 Toddler 6-6.5 Toddler 7-7.5 Toddler 8-8.5 Toddler 9-9.5 Toddler 10-10.5 Toddler 11 Little Kid 11.5 Little Kid 12 Little Kid 12.5 Little Kid 13 Little Kid 13.5 Little Kid 1 Little Kid 2 Little Kid 3 Litttle Kid 3.5 Big Kid 4 Big Kid 4 Big Kid 5 Big Kid 6 Big Kid > 6 Big Kid
Clothing size:	* required
Please list any additional medical concerns:
How may we assist you:
Comments:
Registration is a two-part process.  After submitting the registration form you will receive an email request for two photos of the face; one of which should be a front view and the other should be a profile view.  Potentials Foundation Review Board verifies all submissions before access to the foundation is given.