Organization Name Primary Contact Name Phone Number Website Email Is this Organization a Nonprofit? Yes No Organization Type (Check all that apply) Science Advocacy Medical Education/Support Other Other Organization Type Primary Disease Focus – None –Angelman SyndromeAtaxia-telangiectasiaAutism Spectrum DisorderBrain TraumaCanavan’s DiseaseCerebral PalsyDown SyndromeEpilepsyHurler’s SyndromeHydrocephalusHypoxic InjuryIntraventricular HemorrhageKrabbe’s DiseaseLeukodystrophyPervasive Developmental DisorderRett SyndromeSandhoff DiseaseSanfillipo SyndromeSpinal Muscular AtrophyStroke, Pediatric or In-uteroTay-Sachs DiseaseUndiagnosed Brain ConditionOther… Please Describe Other Disease Focus Primary Project/Program/Activity Is there a common link to the mission of Pediatric Brain Foundation? Additional Notes/Comments/Questions Submit
