Parent Partner Project Application

this information is to help us determine eligibility and provide a matching Parent Partner
any information you provide on the application form or share with a Parent Partner will be kept confidential

Name(Required)

First Last

What is the name of the Parent Partner you would like to request as a match?(Required)

What is your connection to Glut1 Deficiency?(Required)

What is the current age of your loved one with Glut1 Deficiency?(Required)

At what age was the Glut1 Deficiency diagnosis made?(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

What type of support are you looking to receive through the Parent Partner Project? Are there specific questions, concerns, or challenges you are hoping to address?(Required)

Any additional information you would like to share:

Agreements for participation:(Required)

I agree to release the Glut1 Deficiency Foundation and its board members, staff, and volunteers from any claims of harm or injury as a result of the Parent Partner Project.