Next Step Kit Request Form Next Step Kit Request Before You Begin Please confirm this request is for someone * 18 years or younger A United States Resident: Please note, HA currently ships to residents in the US Your Information Name * Name First First Last Last What is your connection to the Hydrocephalus Association? * I have hydrocephalusI am a parent of someone with hydrocephalusMy mother or father has hydrocephalusI am a spouse-partner of someone with hydrocephalusI am a caregiver for someone with hydrocephalusI have an immediate family member with hydrocephalusI have an extended family member with hydrocephalusI have a co-worker with hydrocephalusI have a friend with hydrocephalusI am a healthcare professional and/or researcherI am an event sponsorI don't have a personal connection to hydrocephalusI prefer not to answer Email * How do you identify? (Why we ask this question: we want to make sure we are connecting with everyone within our community and would like to ensure gender diversity in our responses.) FemaleMaleNon-binaryPrefer to self-describeTransgender As we develop programs and resources to empower our diverse community, please select the response that best reflects your racial or ethnic identity. American Indian or Alaska NativeAsianBlack or African AmericanHispanicMiddle EasternNative Hawaiian and Other Pacific IslanderSoutheast AsianWhite or CaucasianOtherTwo or more of the above listed Mailing Information: Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Child's Information Patient's Name * Patient's Name First First Last Last Patient DOB * Patient Diagnosed Age * Infant (1-11 months)Prenatal DiagnosisAt Birth DiagnosisChild (1-12)Teen (13-18)Young Adult (19-25)Young and Middle Aged (26-59)Older Adult (60+) Hospital/Institution Referred by * Primary Doctor Referred by (optional) Section Would you like to help offset costs for HA? Cover Shipping Would you like to gift a bear? Donate a Bear Total Payment Payment Payment Payment Month 123456789101112 Payment Year 20252026202720282029203020312032203320342035 Payment Captcha Submit If you are human, leave this field blank. Δ Was this resource helpful? Yes No Submit Cancel Thanks for your feedback!
