Parent Contact us Form

If you are a parent for a child with disability, please fill in the following questions:

Child Name *
Your Child Medical Diagnosis is:
Child's Age is:
Reason For Contacting Us is
How Did You Hear About Us :
Do You Like to Participate in the Registry Program?
If yes, please provide your Mobile Number :(Obligatory)
And your email address:(Optional)
Preferred Way of Contacting you is:

In case you chose the email form of contacting, you will receive an email with "CPUP-Jordan" in the subject bar.

Best Time to Reach you is:

Get in Touch!

Telephone: (+962)776152995

CPUP - Jordan