Potentials Foundation

Your contact information:
Full name:	* required
Names of parents:	* required
Names of sibblings:
Email address:	* required
Street address:	* required
City:	* required
State, Province, or Region:	* required
Postal Code:	* required
Country:	* required
Telephone number:
Alternate phone number:
Add my contact info to the family directory:	Yes No
Additional information:
MOPDII Diagnosis:	confirmed unconfirmed
Name of diagnosing physician:	* required
Date of birth:	* required
Birthweight & Term:	* required less than 28 weeks 29-30 weeks 31-32 weeks 33-34 weeks 35-36 weeks 37-38 weeks full term
Length at birth:	* required inches centimeters
Head circumference at birth:	* required inches centimeters
Current weight:	* required pounds grams kilograms
Current height:	* required inches centimeters
Current head circumference:	* required inches centimeters
Eye glasses:	Yes No
Hearing aids:	Yes No
Shoe size:	* required
Clothing size:	* required
Activities, hobbies, interests:
How may we assist you:
Comments:
Registration is a two-part process.  After submitting the registration form you will receive an email request for verification of the MOPDII diagnosis.  A profile photo plus additional supporting information is required.  Potentials Foundation Review Board verifies all submissions before access to the foundation is given.