Community Program Enrollment Form

Parent #1 *

Parent #2

Email Address *

Phone Number

I consent to receiving SMS from Project Alive *

Yes

No

Street Address *

City State Zip Code *

How many of your children have/had Hunter syndrome? If you are an adult with Hunter syndrome, please write "self." *

Child with Hunter syndrome #1 *

DOB (MM/DD/YYYY) of child/adult 1 with Hunter syndrome *

Date of passing if applicable (MM/DD/YY).

Which form of MPS II does your child/ren or yourself have? *

Treatments received *

None

ERT

Stem Cell Transplant

Gene Therapy

Blood Brain Barrier Penetrating ERT

Itrathecal

If in a clinical trial, please specify which one

Child with Hunter syndrome #2

DOB (MM/DD/YYYY) of child/adult 2 with Hunter syndrome

Date of Passing (if applicable)

Form of Hunter syndrome child #2

Treatments Received

If in a clinical trial, which one?

Child with Hunter syndrome #3

DOB Child #3 (MM/DD/YYYY)

Date of Passing (if applicable)

Form of Hunter syndrome Child #3

Treatment received

Race/Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Household Income *

Household Size *

Do you receive any government assistance? *

WIC, SNAP, other food assistance

SSI

Housing Assistance

State Financial Assistance

IHSS

Other

No Assistance Received

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