Name
Address
Telephone
Mobile
Email

Relationship to person with fragile X:

• Parent(s)

  Please provide information about your children with fragile X:

  Name Sex Birth year Diagnosis year
  Name Sex Birth year Diagnosis year
  Name Sex Birth year Diagnosis year
  Name Sex Birth year Diagnosis year

• Professional Profession

• Other Relative, friend, student, carer, other?

Questions, comments

I give my permission to have my name and contact details passed on to other families in my area: Yes No

The Fragile X Trust (NZ) is a charitable organisation that relies on your donations to operate. We request an annual donation of $10 or more per family to assist our endeavours. Donations over $5 are tax deductible.

Payment can be made to the Fragile X Trust via internet banking or through an ASB bank (account details will be emailed to you). Or send your donation to: Fragile X Trust (NZ), 196 Taita Drive, Lower Hutt 5011. Please make cheques payable to: Fragile X Trust (NZ).

All information obtained is for the sole purpose of the Fragile X Trust (NZ) as directed by the Privacy Act 1993. Information will not be given to a third party without your written consent. For more information: Email admin@fragilex.org.nz, Phone: 0508 938 0552