Celiac Kids Connection new member information Please complete this information in order for us to process your membership. If you have any questions, please contact celiac@childrens.harvard.edu. Parent's Name Street Address City, State, Zip Code Phone Number Your email Child's Name Gender (optional) Date of Birth Date of Diagnosis Associated medical problems (such as diabetes or downs syndrome) Other family members with celiac disease Physician and hospital affiliation Within the past 12 months we worried whether our food would run out before we got money to buy more. Often TrueSometimes TrueNever TrueDon't KnowDecline to Answer Within the past 12 months the food we bought just didn't last and we didn't have money to buy more. Often TrueSometimes TrueNever TrueDon't KnowDecline to Answer This form uses Akismet to reduce spam. Learn how your data is processed. Δ
