Parent Information Form
Parents, please provide information about your son(s) with Lowe syndrome: (please print; use extra paper if needed)
A. Name of Son(s) with Lowe syndrome Son(s) Date of Birth
son's first & last name 
 		 month day year
son's first & last name
 		 month day year 
B. Family Information Please complete, if applicable: 

1. Family Web site: http://                                                                                                                

2. Languages spoken other than English: _____________________________________________________

3. If you are not the biological parent of your child with LS, please check:
Check box imageAdoptive parent Check box image Foster parent Check box imageOther:_____________ 
C. Permission to Release Name: I give permission for the LSA to include my name, address, phone number, and son's name and birth date in the annual Parent Directory, and to share my name with other LSA parents as appropriate.
 Check box imageYES  Check box imageNO 
D. Research Roster: I give permission for the LSA to provide my name, address, phone number, and child's name and birth date to legitimate researchers who are working on LS. I understand I am under no obligation to participate in any research project about which I am contacted.
 Check box image YES Check box imageNO
Your Signature: Today's Date: