Pen Pal Request Form Pen Pal Request Form Your Name * Your Name First First Last Last Child's Name * Child's Name First Name First Name Last Name Last Name Child's Date of Birth * Please select child's gender FemaleMale Email * Phone * 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 What is your and your child's preferred method of communication? Parent Email Address Home Address: Written Letter Hydrocephalus Type Normal Pressure Hydrocephalus (NPH)X-Linked HydrocephalusCongenital HydrocephalusAcquired HydrocephalusAdult Onset Hydrocephalus (SHYMA)Posthemorrhagic Hydrocephalus of Prematurity (PHH)Unknown/Unsure Child's Diagnosed Age * Prenatal DiagnosisAt Birth DiagnosisInfants (1 month-11 months)Child (1-12)Teen (13-18)Young Adults (19-25)Young and Middle Aged (26-59)Older Adult (60+) Primary Cause of Hydrocephalus * Aqueductal StenosisArachnoid CystBrain TumorChiari I MalformationDandy Walker MalformationHead Injury, not otherwise specifiedInfection (e.g. meningitis, ventriculitis, encephalitis)Spina Bifida.MyelomeningoceleSubarachnoid HemorrhageOther Hemorrhage (e.g. intraventricular, cerebellar)Unknown/UnsureOther Please select current and past treatments: * Endoscopic Third Ventriculostomy (ETV) Endoscopic Third Ventriculostomy (ETV) & Choroid Plexus Cauterization (CPC) No Treatment Shunt Shunt and ETV Primary Shunt Type Ventriculo-peritoneal (VP) Shunt (Ventricle/Peritoneal Cavity) Ventriculo-atrial (VA) shunt (Ventricle/Right atrium of the heart) Ventriculo-pleural (VPL) shunt (Ventricle/Pleural cavity) Other Please check all that apply: Congenital Hydrocephalus Acquired Hydrocephalus Aqueductal Stenosis Premature Chiari Malformation Dandy Walker Spina Bifida/Myelomeningocele Intraventricular Hemorrhage Cerebral Palsy Brain Tumor Meningitis Visual Impairment Twins Slit Ventricle Syndrome Physical Impairment Numerous Revisions Developmental Delays Learning Disabilities Special Education Regular Education Growth Disorder L1CAM (X-Linked Hydrocephalus) Traumatic Brain Injury (TBI) Non Verbal Learning Disorder (NVLD) Pseudo Tumor Cerebri Arachnoid Cyst Sudden ETV Closure Complications (select all that apply) Anxiety Brain Damage Depression Developmental Delays Growth Disorder Learning Disorder Memory Challenges Numerous Revisions Physical Impairment Seizures Slit Ventricle Syndrome Multiple Shunts Special Education Sudden ETV Closure Visual Impairment By participating in the HydrocephalusConnect Pen Pal Program, I acknowledge that my child's actions are fully independent of the Hydrocephalus Association. I, the parent, agree to the following guidelines:1. Monitor my child's pen pal communications at all times.2. Take full responsibility for the nature of the content in my child's letters.3. Report rude and inappropriate messages to the Support Programs Manager at the Hydrocephalus Association.4. Participation in the program is at-will (either child in a match can opt out at any time), however, we suggest participants commit to the program for a minimum of six months to allow the pen pal relationship time to develop. I AGREE that my child can participate in the HydrocephalusConnect Pen Pal Program. HA has my permission to provide my preferred method of contact to HA pen pall volunteer parents. Please sign and date below to agree to our Pen Pal Guidelines. Signature * signature keyboard Clear Submit If you are human, leave this field blank. Δ Was this resource helpful? Yes No Submit Cancel Thanks for your feedback!
