CACNA1A Foundation Contact Registry This survey is HIPAA compliant. Question Title * 1. What is your contact information? First Name * Last Name * Address Address 2 City/Town * State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Country * Email Address * Phone Number Question Title * 2. What is your preferred language? Question Title * 3. How did you learn about the CACNA1A Foundation? CACNA1A/Cav2.1 Facebook Group or other group on social media Searching the Web (e.g. Google) Genetic testing company Referral from friend or family Neurologist or other clinician other Other (please specify) Question Title * 4. What is your affiliation to CACNA1A? Adult with CACNA1A Parent/caregiver/legal guardian of a person with CACNA1A Family member of a person with CACNA1A Friend of a person with CACNA1A Medical Professional Researcher/Scientist Other Other (please specify) Next