BEARS Brain Donor Registration Form
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UC Davis MIND Institute
Brain Endowment for Autism Research Sciences (BEARS) Program
24-Hour Toll Free Phone: (855) 221-HOPE (4673)
Email: mindbears@ucdavis.edu
Fax: (916) 703-0483


The BEARS Tissue Program is committed to advancing research in the area of neurodevelopmental disorders. Completion of this registration form will provide us with the necessary information to coordinate tissue recovery when a potential donor passes away. All information will be kept confidential and used solely by the BEARS Tissue Program.

Demographic Characteristics
Today's Date
* must provide value
   Y-M-D
YYYY-MM-DD
Donor's First Name
Donor's Last Name
Donor's Date of Birth
* must provide value
   Y-M-D
YYYY-MM-DD
Contact Information
Street Address
City
State
Zip Code
Phone number
Include Area Code
Second phone number
Include Area Code
E-mail
Gender
* must provide value
Please choose one
Select all that apply
Autism
Aspergers
Pervasive Developmental Disorder
Celiac Disease
ADD/ADHD
Epilepsy
Anxiety Disorder
Depression
Obsessive Compulsive Disorder
Sensory Issues
Fragile X
Down Syndrome
Neurofibromatosis
Williams Syndrome
Tuberous Sclerosis
22q deletion
Tourette Syndrome
None or other
If other, please specify
Date of Autism diagnosis    Y-M-D
Date of Aspergers diagnosis    Y-M-D
Date of Pervasive Developmental Disorder diagnosis    Y-M-D
Date of Celiac Disease diagnosis    Y-M-D
Date of ADD/ADHD diagnosis    Y-M-D
Date of Epilepsy diagnosis    Y-M-D
Date of Anxiety Disorder diagnosis    Y-M-D
Date of Depression diagnosis    Y-M-D
Date of Obsessive Compulsive Disorder diagnosis    Y-M-D
Date of Sensory Issues diagnosis    Y-M-D
Date of Fragile X diagnosis    Y-M-D
Date of Down Syndrome diagnosis    Y-M-D
Date of Neurofibromatosis diagnosis    Y-M-D
Date of Williams Syndrome diagnosis    Y-M-D
Date of Tuberous Sclerosis diagnosis    Y-M-D
Date of 22q deletion diagnosis    Y-M-D
Date of Tourette Syndrome diagnosis    Y-M-D
Name of parent/guardian, spouse or caregiver (if applicable)
Relationship to donor
Contact Information
Street Address
City
State
Zip Code
Daytime telephone
Include Area Code
Evening telephone
Include Area Code
Fax Number
Include Area Code
E-mail address
Please check the following if you are interested in
Receiving information about our brain donation program
Volunteering for the BEARS Tissue Program and/or for fundraising events
Receiving a copy of the BEARS brochure
Educational Opportunities
Making a financial contribution
Receiving current research news
How did you hear about us?
Receive materials by email or regular mail?
email
regular mail
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