This form is only to be completed if you do not want the child/dependent’s information to be collected for the Registry

Declaration by Parent/Guardian

I do not wish for the child/dependent to participate in the Registry and I understand that my decision will not affect the child’s future health care.
I have read the attached Participant Information Sheet.
I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.

Name of Parent/Guardian

Child/Dependent Name

Child/Dependent Date of Birth

Parent/Guardian Phone

Child/Dependent Primary Heart Doctor (if known)

Date Registry Information Provided (i.e. card issue or invitation received)

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