Celiac Kids Connection Membership Form

Please complete all fields with accurate information.

We use your name and address information for mailing purposes, so it's important that we have complete details. Please provide your full name (first and last) and complete address including street number, street name, city, state, and ZIP code. Incomplete information may result in delivery issues with your membership materials.

Parents Full Name

Street Address (number and street name)

City, State, Zip Code

Phone Number

Your email

Child's Name

Gender (optional)

Child's Date of Birth

Child's Date of Celiac Disease 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

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