First Name * Last Name * Email * Phone How can we help you? Newsletter Check this box to subscribe to our newsletter. Help Pediatric Brain Foundation shine a light on this often invisible and underrepresented community by letting us know about the child in your life. I am (a) ParentGrandparentRelativeCaregiverEducator / TeacherFriendPhysical TherapistPhysicianScientistPersonally AffectedNone, Interested Party Child’s Diagnosis Angelman SyndromeAtaxia-telangiectasiaAutism Spectrum DisorderBrain TraumaCanavan’s DiseaseCerebral Cavernous MalformationCerebral PalsyDown SyndromeEpilepsyHurler’s SyndromeHydranencephalyHydrocephalusHypoxic InjuryIntraventricular HemorrhageKrabbe’s DiseaseLeukodystrophyLeukoencephalopathy with Vanishing White MatterPervasive Developmental DisorderPitt-Hopkins SyndromeRett SyndromeSandhoff DiseaseSanfillipo SyndromeSpinal Muscular AtrophyStroke, Pediatric or In-uteroTay-Sachs DiseaseUndiagnosed Brain ConditionOther… Please Describe Other Diagnosis Child’s Name Child’s DOB Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071 Submit