The Cerebral Palsy Registry in Jordan

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 :

Hospital

Center

School

Specify your own value:

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:

By Phone.

By E-mail.

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:

Attachments

Telephone: (+962)776152995
Email: cpup@ju.edu.jo
Website: sites.ju.edu.jo/en/cpup