Midwest Heart Connection Membership Registration

Please fill out as completely as possible.

Membership Category *
Type of Membership (check all that apply) *
CHD Family (Your Child has CHD) Supporter (Friend, other relative, etc. has CHD) Board Member (Past or Present) Donor Medical Professional
How did you hear about us? *
If other above, please explain
Mom's Name (or other adult) * First Last
Email *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - ### - ### ####
Dad's Information (or other adult)
Dad's Name First Last
Email
Address (if different from above)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - ### - ### ####
Family Information
Name of person with congenital heart disease First Last
CHD person's defect(s)
Gender
Male Female
CHD person's date of birth / MM / DD YYYY
Names of CHD child's siblings
Other Information
May we contact you by the following?
By Phone By Email
How can MHC best help you through your CHD journey?
You may also upload a photo of your CHD child or family.
By checking the box below you grant MHC permission to use the transmitted photo in advertising and/or other MHC publications.
I agree
Would you like to be involved in Midwest Heart Connection?
Volunteer (at special events and/or help coordinate programs) I would like to share my family's story to help raise awareness or help others
Would you like to donate to Midwest Heart Connection, via PayPal, to help support our programs and mission?
No, Thank you! $10 $25 $50 $100
Spam Protection. Please answer this simple question.
What is "seven hundred" as a number?
$0

Total

Midwest Heart Connection Membership Registration

Midwest Heart Connection Membership Registration

Dad's Information (or other adult)

Family Information

Other Information

$0

Total

$`0`