IS Heroes Award Nomination Form

  
 

Please fill out the form to nominate a Healthcare Professional you believe qualifies as an IS Hero.

*Required fields marked with asterisks.

First tell us about yourself:
*First Name:
*Last Name:
*Email:
*City:
*State:
*Zip:
*Phone:
*Name of child with IS?:
*Relationship to child?
*Month & Year first diagnosed with IS?  
*How was disease diagnosed or characterized?
*Description of treatment?
*Outcome

Now tell us about your Healthcare professional:
*First Name:
*Last Name:
*Email:
*Institution:
*City:
*State:
*Zip:
*Phone:

Please answer the following questions in essay form so we may learn more about your experience with IS and the healthcare professional you are nominating for the IS Heroes Award.

Tell us about your child and your story with Infantile Spasms. When was your child first diagnosed with IS? What were his/her symptoms? How soon did your child receive treatment? What is your child's life like today?


Tell us about your hero! Think about what makes this person special. How is this person advancing the understanding of IS? Why does your nominee deserve recognition as an IS Hero? Please be specific in detail.

 

 

 
DEC 6th-10th 2013
Providing pediatricians,
child neurologists, parents
and caregivers with objective educational tools which will
increase the understanding of IS.
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