Bright Horizons Application

to help us determine eligibility and prepare for the sessions

Name(Required)

First Last

Email(Required)

Address(Required)

City State / Province / Region Country

What is your connection to Glut1 Deficiency?(Required)

I have a Glut1 Deficiency diagnosis

I am the parent or caregiver of someone with a Glut1 Deficiency diagnosis

What is the name of the person with Glut1 Deficiency?(Required)

What is the age of the person with Glut1 Deficiency?(Required)

At what age was the diagnosis made?(Required)

What type of behavioral support are you hoping to receive through the Bright Horizons Project?(Required)

Who would you like to attend the Bright Horizons Project session?(Required)

person with Glut1 Deficiency

parent/caregiver(s)

other

check all that apply

Agreements for participation:(Required)

I agree to meet requirements for services from the Bright Horizons Project

I agree to complete a brief survey after my Bright Horizons session

I agree to release the Glut1 Deficiency Foundation from any claims of harm or injury

Any additional information you would like to share:

next steps

your application will be reviewed by the Glut1 Deficiency Foundation
you'll be notified of the decision within a week of application submission
if approved for participation in the Bright Horizons Project, a referral will be made Behavior Support Specialist Dana Pottschmidt
you'll be introduced to Dana by email to further coordinate