Kids With Heart NACHD, Inc. Disclaimer:
The intention of this information is to give parents of children with congenital heart disorders a place to find information about specific disorders and other support resources.  Kids with Heart National Association for Children's Heart Disorders, Inc. personnel are not doctors or medical personnel.  In no way should any information found on this site be a substitute to professional medical care or attention from a qualified practitioner nor should it be inferred as such.  ALWAYS check with your child's doctor if you have any questions or concerns about any diagnosis, symptoms, or treatments.

Registration Form for Kids With Heart Nat'l Assoc. for Children's Heart Disorders

Registering to become a member of Kids With Heart is completly free!  Registering with us will enable you to participate in the variety of services that Kids With Heart National Association for Childrens Heart Disorders has to offer.  Just fill out the form below and check the services that interested you.  Fill out as much information as you feel comfortable.  When requesting parent matching services, a mailing address is required.

Note ~ Your personal information will not be released to solicitors or advertisers!
1 in 100 children are affected by congenital heart defects.

Since 1985, Kids With Heart has been providing support, education, and awareness for heart families.
Contact Us:
Kids With Heart National
Association for Children's
Heart Disorders, Inc.
1578 Careful Dr
Green Bay, WI 54304-2941
(800)538-5390
(920)498-0058 (Outside US)
michelle@kidswithheart.org


Learn more about us
Parent's Name:
Street Address:
City:
State:
Zip:
Email:
Phone:
How did you hear about Kids With Hearts:
Heart Child(ren) Name(s):
Child's Birth Date: (mm-dd-yy)
Description of Heart Defect(s):
   
Please check appropriate complications  
- Seizures  
- Pleural Effusions  
- Pericardial Effusions  
- Strokes  
- Hydrocephalus  
- Chylothorax (Nicking of Lymph Gland)  
- Cardiac Arrest  
- Hemolysis  
   
Other Medical Conditions  
Surgery Date(s) and proceedures: (ex. repair of TOF, fontan, etc. 10/5/03)
1.
2.
3.
4.
5.
6.
   
Cardiologist(s):
Heart Surgeon(s):
Hospital(s) Used:
Would you go back: - Yes - No
Helpful Comments (re: hospital, surgeon):
Follow Up Care facility:
Medications:
   
Siblings & Their Birth Dates: (Brian 12-15-99)
1.
2.
3.
4.
5.
6.
   
Services Requested:  
- Information on a local group, if available in your area
- Parent Matching - Matches parents of children with same CHD
- ACHD to ACHD Matching - Matches adults who have same CHD
- ACHD to Parent Matching - Matches adults (ACHD) with parents of a child with same CHD as adult with CHD.
- Meeting/Event Announcements (Green Bay Area Only)
- Participating In Research Regarding Heart Defects
   
- I give the Kids Heart National Association for Children's Heart Disorder, Inc. permission to release my name for the sole use of parent matching, research on heart defects, etc. Your personal information will not be released to any solicitors or advertisers!