CACNA1A Cure Club Enrollment Survey

We know that high-quality data from our community is crucial for advancing research and finding a cure for CACNA1A-related disorders. We also know that life with CACNA1A-related disorders can be challenging and overwhelming.

The CACNA1A Cure Club was created in response to feedback from our community, which indicated that many people want to contribute to research but would appreciate reminders about applicable research opportunities. The Cure Club aims to increase participation in CACNA1A research by providing personalized, simple, and manageable reminders.

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* 1. What is your name?

First Name

Last Name

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* 2. What is the name of the person with a CACNA1A variant (if not yourself)?

First Name

Last Name

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* 3. What is your contact information?

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. What is your name on Facebook?

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* 5. What is your Instagram handle?

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* 6. It is the CACNA1A Cure Club’s goal to only send you reminders for research that applies to the person with a CACNA1A variant. Please select all that apply.

Ataxia

Cognitive

Developmental Delays

Eye Movement Disorder(s)

Epilepsy

Hemiplegic Migraine

Speech & Language

Pediatric Patient

Adult Patient

U.S. based

International

English speaking

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* 7. Would you like to receive the CACNA1A Foundation's monthly newsletter?

Yes

Already Receive

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* 8. Please select your preferred forms of communication from the CACNA1A Cure Club (select all that apply)

Text Message

Phone Call

Paper Mail

Facebook Messenger

Instagram Messenger

What's App

Other (please specify)

Thank you for joining the CACNA1A Cure Club! Your participation makes a difference. Please be on the lookout for a confirmation email.