Canadian Prader-Willi Syndrome Organization 2788 Bathurst St, Suite 303, Toronto, Ontario Phone (416)481-8657, 1-800-563-1123 Fax 416-481-6706 e-mail: opwsa@rogers.com web: www.pwsacanada.com Charitable Registration: 867272684 RR 0001. CONTACT FORM - 2008 Name: __________________________ Agency (if applicable): __________________________ Street: __________________________ City: __________________________ Province: __________________________ Postal Code: __________________________ Phone No. Home: __________________________ Phone No. Work: __________________________ Fax: __________________________ Email: (include only if we can use for contacting you)  __________________________ I can be contacted by professionals doing research. Yes _____ No _____ I can be contacted by other families. Yes _____ No _____ My child's name can be included on the membership list.       Yes _____ No _____ Name of Person with Prader-Willi Syndrome. ___________________ Male ____ Female ____ Date of Birth:    Day: ________ Month: ________ Year: ________ CPWSO Profile Sheet Please help us. By filling out this form CPWSO can keep our information up-to-date. Complete information is helpful for data collection & advocacy. Please add a separate sheet if further space is required and include a picture if you wish. All information is kept confidential. Name of Person: ________________________ Male ____ Female ____ Date of Birth:    Day: _________ Month: _________ Year: _________ Genetic Diagnosis: _________________________________________________ Medical - including alternative supplements used: Current Medical Conditions ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Medications for Condition ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Physician /Specialist Treating ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Supports Currently Used: (Name of Agency, Phone Number - Contact Person - use separate sheet if necessary) Pediatrician/Family Practitioner: _____________________________________________ Psychologist/Behavioural Services: _____________________________________________ Psychiatrist: _____________________________________________ Endocrinologist: _____________________________________________ Other Medical Specialist: _____________________________________________ Residential Provider: _____________________________________________ Summer Camp: _____________________________________________ Day/Work Program: _____________________________________________ Occupational/physiotherapy: _____________________________________________ Speech: _____________________________________________ Dietician: _____________________________________________ Financial Support Received: Provincial _____   Federal _____ To send your information to us, print it out, fill it in, and mail or fax it to us at:       Canadian Prader-Willi Syndrome Organization       2788 Bathurst St, Suite 303       Toronto, Ontario       Phone: (416)481-8657, 1-800-563-1123     Fax: 416-481-6706       Email: opwsa@rogers.com Thank-you