IS Care Package Request Form

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Infantile Spasm Care Package Request Form

First Name *

Last Name *

Email *

Phone 1 *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country *

Preferred Method of Contact

Data Privacy & Consent

Yes, I would like to receive text messages from Team Iron Will.

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Password

Retype Password

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Child's Full Name

Your Relationship to Child *

Child's Date of Birth

Do they have a confirmed diagnosis of Down syndrome? *

Yes

If there are siblings in the home, please list their ages.

We like to include something in our care packages for siblings :-)

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Is your child currently experiencing infantile spasms? *

Yes

If no, please explain why you are requesting this care package for infantile spasms:

If you'd like to join our support group on Instagram please share your IG account.

This is a group of over 30 moms who have all been through IS and would love to walk with you through this journey.

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Is there anything else you’d like us to know about your situation or request?

By submitting this application, I confirm that the information provided is accurate to the best of my knowledge. I understand that completing this application does not guarantee assistance. *

I agree

Care packages are usually sent within 7 days of receiving your information.

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