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THE PROGERIA RESEARCH FOUNDATION INTERNATIONAL PROGERIA REGISTRY

Hutchinson-Gilford Progeria Syndrome (Progeria) is a very rare condition. This International Registry has been established toprovide services and information to families of children with Progeria, treating physicians, and researchers, and to better understand the nature and natural course of Progeria. This serves toimprove communication of ideas among interested researchers, and assures rapid distribution of any new information that may benefit patients and/or their families. Your cooperation in registering and inhelping to contribute information on Progeria individuals to the Registry is greatly appreciated. PRF considers confidentiality a high priority. The personal identifying information you submit onthese forms will not be distributed in any way without explicit consent from the Progeria subject or their parent or guardian. You may email the completed forms to info@progeriaresearch.org orReturn completed forms directly to Registry Headquarters: The Progeria Research Foundation, Inc. PO Box 3453 Peabody, MA 01961-3453 USA FedEx or other delivery address: 2 Bourbon Street, Suite 208,Peabody, MA 01960 Website: www.progeriaresearch.org Telephone: (978) 535-2594 Fax: (978) 535-5849
PRF OFFICE USE ONLY Date contacted:______________ By whom: __________________ Method of contact: EmailPhone Other: ________________

Update 10/15/2010

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The Progeria Research Foundation

PRF International Progeria Registry Registration of Progeria Subject Who is registeringthis Progeria Subject? Name:_________________________________________________________________ Title:__________________________________________________________________Specialty:_______________________________________________________________ Address:________________________________________________________________ Telephone:______________________________________________________________ Email:...