Gender (required)
FemaleMale

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If they are no longer living, at what age did they pass away? (required - if not applicable, please write N/A)

Your Relationship to this person: (required)
Mother/StepmotherFather/StepfatherFoster Parent/GuardianGrandparentOther relativeSibling

Has a diagnosis been confirmed? (required)
YesNo

What Form? (required)
PLA2G6-Associated Neurodegeneration (PLAN)- Infantile neuroaxonal dystrophy (INAD)PLA2G6-Associated Neurodegeneration (PLAN)- Atypical neuroaxonal dystrophy (ANAD)PLA2G6-Associated Neurodegeneration (PLAN)- Dystonia-parkinsonismUnsure

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Other comments

If you answer yes to any of the below, someone from the INADcure Foundation will reach out to you soon at the email address provided.

Please check all that apply:
I would like to join the INADcure Private Facebook Group (family members only).I would like to help raise awareness about INAD in my community.I would like to volunteer with the INADcure Foundation.I would like to learn about how I can help raise funds for the INADcure Foundation and support INAD research.

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By filling in the form above, I am giving the INADcure Foundation permission to send me occasional emails and/or mailings. (required)