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Activation Form

Introduction

Please answer a few questions to help us create your participant account. If you have any questions, please contact cords@sanfordhealth.org or 1 (877) 658-9192.

Participant Type

Participant Information

Please provide your basic information. Red asterisk (*) indicates a required field.

Please provide your child’s basic information. Red asterisk (*) indicates a required field.

Please provide the participant’s basic information. Red asterisk (*) indicates a required field.

Parent/Guardian/LAR Information

As the participant's Legally Authorized Representative (LAR), you will be the primary contact. Please provide your own information below in this section.

As the participant's Legally Authorized Representative (LAR), you will be the primary contact. Please provide your own information below in this section.

Enrollment Information

Diagnosis

Please select the participant's diagnosis from the "Rare Disease Diagnosis" section. You can add or remove multiple diagnosis from the field with a maximum entry of 5 diseases.

  • If you have not officially been diagnosed with a Rare Disease, please enter "Undiagnosed or Unaffected Carrier" (along with a rare disease) if applicable to the participant.
  • If you can not find your disease search for "Other" and add your diagnosis in the Other Rare Diseases Diagnosis below.

Consent

Assent

By checking this box, I agree to participate in the CoRDS Registry
Submit
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