VIP Sibling

The VIP Sibling Project

VIP siblings are siblings who have a brother or sister with a rare epilepsy. They are often unselfish, dedicated, and are able to see past the challenges, exhibiting understanding and compassion beyond their years. But they need our support. That’s why we collaborated as part of 10 dedicated patient organizations of the rare epilepsy community to create three very special kits, useful forms, digital downloads, and much more.

We want to thank UCB for the continued collaborative effort that allows us to provide these important resources to support siblings and their families.

Learn more about the VIP Sibling Project and order your links below:

• .
  VIP Siblings

  Parent or Guardian Name *

  Full Name

  Email *

  I confirm that I am 13 years or older. (If you are under 13, please have a parent or legal guardian complete this form.) *

  Yes

  No

  I would like to receive information on future sibling events or initiatives. *

  Yes

  No

  I would like to request a Parent & Caregiver Resources Kit *

  Yes

  No

  I am a member of Connect CDKL5 (required for kit delivery - register at www.cdkl5.com/connect-cdkl5) *

  Yes, I am a member of Connect CDKL5

  I am not sure if I am a member of Connect CDKL5

  Child Name *

  Child Name

  First

  First

  Last

  Last

  Age * Available in two age-appropriate versionsAges 4-10Ages 11-18

  Child Name

  Child Name

  First

  First

  Last

  Last

  Age Ages 4-10Ages 11-18

  Child Name

  Child Name

  First

  First

  Last

  Last

  Age Ages 4-10Ages 11-18

  Address where kit(s) should be mailed *

  Address where kit(s) should be mailed

  Address where kit(s) should be mailed

  Address where kit(s) should be mailed

  City

  City

  State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

  State/Province

  Zip/Postal

  Zip/Postal

  Phone *

  Special Notes or Comments

  Submit

  If you are human, leave this field blank.