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© 2011 - 2012, Hemispherectomy Angels, Inc., a Non-Profit Corporation501(C)3 Tax-ID Number 26-2864993                       Disclaimer of warranties and liability | Web Design by Rachel Waters

PO Box 1239  | Aledo, Texas 76008                                                                                          All Accounting Services Provided by Shelton, Mead, and Shelton, CPAs
Register
Why registration is important for our work at the Hemispherectomy Foundation:

When people make themselves known to us we can document the incidence of hemispherectomies. The Hemi Foundation receives no US Census figures and no reports from other government sources.  We rely on those who contact us to provide us with statistical data in an effort to advocate for increased services and research.  Our figures are only part of the whole international data pool but each additional piece of the puzzle is valuable.

Your registration also ensures you are kept up to date on Hemi Foundation news, events and enrolls you in our Hemi Hugs program. Also available is our Family Matching program where we connect you with other hemi-families, with your permission. You will also have the opportunity to apply for scholarships, camp tuition assistance and more.

*Contact information and data on patients is kept confidential unless permission is given to share with other hemi-families.



Date of Birth:

City:
State:
Zip Code:
Country:



Alt. Email:

Date of Surgery:
Reason for Surgery:
HME Syndrome:
Hospital:
Surgeon:
Neurologist:
Hemi Side (Brain):
Seizure Free?:
Food Restrictions:

Mother and Father's Last Name(s):
Mother and Father's First Names:
Sibling's Name(s):
Who referred you to us?:
Please list your website or blog:
Connect with other hemi families?:
Give your contact info to hemi families?:
Volunteer for The Hemi Foundation?:
Learn more about the Hemi Foundation?:
Other Comments/Notes:
Today's Date:
Geographical Region (see regions by state to the right):

* Please complete the form   with as much information possible. 
Additional Information
Information About Your Child
Contact us for more information about Hemi Foundation events, or how you can get involved.
Come Join Us!
Regions by state:

Eastern: Indiana, Michigan, Ohio, Kentucky, W. Virginia, Tennessee

North Eastern: Maryland, Delaware, New Jersey, Pennsylvania, New York, Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine

Southern: Virginia, N. Carolina, S. Carolina, Mississippi, Alabama, Georgia, Florida

Central: N. Dakota, S. Dakota, Nebraska, Kansas, Oklahoma, Texas, Minnesota, Iowa, Missouri, Arkansas, Louisiana, Wisconsin, Illinois

Western: California, Oregon, Washington, Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, New Mexico, Hawaii, Alaska