Account Details Username (required)Email Address (required) Choose a Password (required) Strength indicator Confirm use of weak password Confirm new password Hint: The password should be at least twelve characters long. To make it stronger, use upper and lower case letters, numbers, and symbols like ! " ? $ % ^ & ). Profile Details Full Name (required) This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close Username (required) This field may be seen by: Everyone Are you already a member of the XLH Network? (required) Yes (please scroll down and click on "submit request"No (please fill out the remainder of the questions for membership) This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close I understand that membership is limited to the categories below. I am applying for membership because I am a: Living with XLH, ADHR, TIO or ARHR.Family member of those living with XLH, ADHR, TIO, or ARHR.Medical professional with an interest in phosphate wasting disorders.Donor interested in supporting the Network This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close Email: This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close Phone Number This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close Mailing Address: This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close Date of Birth: Day ----12345678910111213141516171819202122232425262728293031 Month ----JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year ----20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close What Type of Member Are You? (Please check all that apply) (required) Adult with XLHAdult with XLH - Spontaneous CaseFamily History of XLHFamily MemberParent of Child with XLHFriend of an XLH PatientPhysicianMedical ProfessionalNetwork MemberOther This field may be seen by: Only Me Change Who is allowed to see this field? Everyone Only Me All Members My Friends Close
