To join CPON, please complete this form:

Child's Name (or Adult name):_________________________________________________

Date of Birth:  ______________________________________________________________

Parent/Guardian names: _____________________________________________________

Email address: _____________________________________________________________

Mail Address:

Street:_____________________________________________________________________

City:_______________________________  State:____________  Zip:_________________

Phone:  Area Code:_________Number:___________________________________________

 

Please send this information by mail or email to:

CPON (Cerebral Palsy Outreach Network)
B601 West Fee Hall 
Department of Epidemiology
Michigan State University
East Lansing, MI  48824
Phone: 517-353-8623 x116  
cpon@epi.msu.edu

Thank-you for your interest in CPON!