Take Heart Conference Registration 2025

Contact Information

Phone Number

What is your country of residence?

United StatesOther

If other, please specify.

Activity Kit

State

Would you like to receive an activity kit in the mail?

YesNo

Mailing Address

Start typing in your address below--spell out street names ("Street" instead of "St" or "Avenue" instead of "Ave").
Click your full address when it pops up in the search. Confirm that it's correct and add any apartment or unit info in the "Street 2" box.
If your address does not come up in search, select each box individually to manually type it in.

Street

Street 2

City

State

Zip

Country

Tell us about your heart condition

Please select your AGE at DIAGNOSIS:

Prenatally	Infant (1 and under)
Preschooler (2-5)	School age (6-12)
Teen (13-17)	Young adult (18-39)
Adult (40+)

Primary Hospital for Care

If other, please specify.

How far away do you live from the hospital?

Are you interested in sharing your story?

YesNo

If yes, please submit here

Are you interested in learning more about the Adult Congenital Heart Association peer support program?

YesNo

Patient Diagnoses

Please take a moment to select all of the diagnoses that are relevant to you.

Single Ventricle Heart Condition

Hypoplastic Left Heart Syndrome (HLHS)	Tricuspid Atresia	Double Inlet Left Ventricle (DILV)
Unbalanced Atrioventricular Canal	Pulmonary Atresia with Intact Ventricular Septum

Two Ventricle Heart Condition

Tetralogy of Fallot (TOF)	Transposition of the Great Arteries (TGA)	Atrioventricular Septal Defect (AVSD)
Ventricular Septal Defect (VSD)	Atrial Septal Defect (ASD)	Coarctation of the Aorta
Double Outlet Right Ventricle (DORV)

Transplant

Status-post Heart Transplant

Listed for Heart Transplant

Post-Transplant Complications

Acquired Heart Condition

Kawasaki DiseaseRheumatic Heart DiseaseMyocarditisInfective Endocarditis

Cardiomyopathy

Dilated Cardiomyopathy	Hypertrophic Cardiomyopathy
Restrictive Cardiomyopathy	Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Pediatric Pulmonary Hypertension

Idiopathic Pulmonary Arterial Hypertension (IPAH)Pulmonary Hypertension secondary to Congenital Heart DiseasePulmonary Hypertension secondary to Bronchopulmonary Dysplasia (BPD)

Vascular Rings/Slings/Tracheal Rings

Double Aortic Arch	Right Aortic Arch with Aberrant Left Subclavian Artery
Pulmonary Sling	Complete Tracheal Rings

Arrhythmia/s

Supraventricular Tachycardia (SVT)Long QT SyndromeComplete Heart BlockVentricular Tachycardia

NICU Related Diagnoses

Bronchopulmonary Dysplasia (BPD)	Persistent Pulmonary Hypertension (PPHN)	Chronic Lung Disease with cardiac strain
Pulmonary Vein Stenosis	Prematurity <32 weeks with cardiac/respiratory compromise	Intraventricular Hemorrhage (Grades III-IV)
Necrotizing Enterocolitis (NEC) with cardiac monitoring	Hypoxic-Ischemic Encephalopathy (HIE)	Seizure disorders from birth trauma or cardiac events
Stroke (perinatal) with cardiac involvement	Genetic syndromes with CHD (e.g., Trisomy 21, 22q11.2 deletion)	Tracheoesophageal Fistula (TEF)
Congenital Diaphragmatic Hernia (CDH)	Omphalocele	Gastroschisis
Intestinal Malrotation with volvulus	Laryngeal/airway anomalies with cardiac compromise	Esophageal atresia
Complex abdominal wall defects	VACTERL association or CHARGE syndrome	Prolonged NICU stay (>4 weeks)
ECMO, VAD, or transplant evaluation	Parental/sibling trauma from diagnosis	Family history of CHD
Complex discharge plans (oxygen, feeding tubes, specialists)

Other

Ebstein's Anomaly	Coronary Artery Anomalies
Sinus of Valsalva Aneurysm	Other Rare or Syndromic CHDs (e.g., CHARGE syndrome, DiGeorge syndrome)

Do they have any additional diagnoses?

GeneticMental HealthOtherNone

Please specify the exact diagnosis/es.

singleVentricle

twoVentricle

transplant

acquiredHeartCondition

cardiomyopathy

pulmonaryHypertension

ringsSlings

arrhythmia

nicuRelated

other

Tell us about your child's heart condition

Child's First Name

Child's Last Name

Child's Preferred Name

Child's Date of Birth

Is your child deceased?

YesNo

If you would like, please provide a photo of your Heart Warrior to include in our dedication collage during the conference.

Please select their CURRENT age group:

Infant (birth to 23 months)	Preschooler (2-5)
School age (6-12)	Teen (13-17)
Young adult (18-39)	Adult (40+)

Child's Gender

If other, please specify.

Child's Pronouns

she/her

he/him

they/them

prefer not to say

other

If other, please specify.

Race/Ethnicity

Select all that apply to your child:

American Indian or Alaskan Native	Asian or Asian American
Black or African American	Hispanic or Latino/a/x
Middle Eastern or North African	Native Hawaiian or Other Pacific Islander
White or Caucasian	Prefer not to answer
Other

If other, please specify.

Please select their AGE at DIAGNOSIS:

Prenatally	Infant (1 and under)
Preschooler (2-5)	School age (6-12)
Teen (13-17)	Young adult (18-39)
Adult (40+)

Primary Hospital for Care

If other, please specify.

How far away do you live from the hospital?

Are you interested in sharing your family's story?

YesNo

If yes, please submit here

Patient Diagnoses

Please take a moment to select all of the diagnoses that are relevant to your child.

Single Ventricle Heart Condition

Hypoplastic Left Heart Syndrome (HLHS)	Tricuspid Atresia	Double Inlet Left Ventricle (DILV)
Unbalanced Atrioventricular Canal	Pulmonary Atresia with Intact Ventricular Septum

Two Ventricle Heart Condition

Tetralogy of Fallot (TOF)	Transposition of the Great Arteries (TGA)	Atrioventricular Septal Defect (AVSD)
Ventricular Septal Defect (VSD)	Atrial Septal Defect (ASD)	Coarctation of the Aorta
Double Outlet Right Ventricle (DORV)

Transplant

Status-post Heart Transplant

Listed for Heart Transplant

Post-Transplant Complications

Acquired Heart Condition

Kawasaki DiseaseRheumatic Heart DiseaseMyocarditisInfective Endocarditis

Cardiomyopathy

Dilated Cardiomyopathy	Hypertrophic Cardiomyopathy
Restrictive Cardiomyopathy	Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Pediatric Pulmonary Hypertension

Idiopathic Pulmonary Arterial Hypertension (IPAH)Pulmonary Hypertension secondary to Congenital Heart DiseasePulmonary Hypertension secondary to Bronchopulmonary Dysplasia (BPD)

Vascular Rings/Slings/Tracheal Rings

Double Aortic Arch	Right Aortic Arch with Aberrant Left Subclavian Artery
Pulmonary Sling	Complete Tracheal Rings

Arrhythmia/s

Supraventricular Tachycardia (SVT)Long QT SyndromeComplete Heart BlockVentricular Tachycardia

NICU Related Diagnoses

Bronchopulmonary Dysplasia (BPD)	Persistent Pulmonary Hypertension (PPHN)	Chronic Lung Disease with cardiac strain
Pulmonary Vein Stenosis	Prematurity <32 weeks with cardiac/respiratory compromise	Intraventricular Hemorrhage (Grades III-IV)
Necrotizing Enterocolitis (NEC) with cardiac monitoring	Hypoxic-Ischemic Encephalopathy (HIE)	Seizure disorders from birth trauma or cardiac events
Stroke (perinatal) with cardiac involvement	Genetic syndromes with CHD (e.g., Trisomy 21, 22q11.2 deletion)	Tracheoesophageal Fistula (TEF)
Congenital Diaphragmatic Hernia (CDH)	Omphalocele	Gastroschisis
Intestinal Malrotation with volvulus	Laryngeal/airway anomalies with cardiac compromise	Esophageal atresia
Complex abdominal wall defects	VACTERL association or CHARGE syndrome	Prolonged NICU stay (>4 weeks)
ECMO, VAD, or transplant evaluation	Parental/sibling trauma from diagnosis	Family history of CHD
Complex discharge plans (oxygen, feeding tubes, specialists)

Other

Ebstein's Anomaly	Coronary Artery Anomalies
Sinus of Valsalva Aneurysm	Other Rare or Syndromic CHDs (e.g., CHARGE syndrome, DiGeorge syndrome)

Do they have any additional diagnoses?

GeneticMental HealthOtherNone

Please specify the exact diagnosis/es.

singleVentricle

twoVentricle

transplant

acquiredHeartCondition

cardiomyopathy

pulmonaryHypertension

ringsSlings

arrhythmia

nicuRelated

other

Tell Us More About Your Profession

What is your company, hospital, or organizational affiliation?

If other, please specify.

Tell us more about your profession.

If other, please specify.

Referral Source

How did you hear about Take Heart?

If hospital staff or other, please specify:

Is this your first time attending Take Heart Conference?

YesNo

Any comments or questions for us?