2025 CCF Family Survey

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Would you like to receive a $10 Amazon gift card? Please complete this short survey to help CCF better serve its families!

Your answers will assist us with our 2026 planning and ensure that our families receive the resources and support services that are most helpful. All answers are confidential.

$10 Amazon gift cards will be delivered electronically to those that complete this form by Friday, November 14, 2025. You must include your name and current email address on this form to receive a gift card. Gift cards will be distributed by Friday, December 5, 2025.

**One gift card per family. Must be over 18 years of age, registered with CCF, and be a parent or family member of a child with cardiomyopathy to receive a gift card. By completing this survey, you agree to CCF reaching out to you regarding your survey responses.

Full Name

Please note: Full name (first and last name) is required if you would like to receive a $10 Amazon gift card.

Email address

Please note: Active email address is required if you would like to receive a $10 Amazon gift card.

What is your relationship to cardiomyopathy? *

I am a parent of a child at-risk or diagnosed with cardiomyopathy.

I am the parent/guardian of a deceased child who was diagnosed with cardiomyopathy.

I am a relative or friend of a child at-risk or diagnosed with cardiomyopathy.

I was diagnosed with cardiomyopathy as a child and am now an adult (age 18 or older).

Other:

Child's Name *

Child's Date of Birth *

YYYY

Child's Age at Diagnosis *

Type of Cardiomyopathy *

Dilated cardiomyopathy (DCM)

Hypertrophic cardiomyopathy (HCM)

Obstructive Hypertrophic cardiomyopathy (HOCM)

Arrhythmogenic cardiomyopathy (ACM)

Restrictive cardiomyopathy (RCM)

Noncompaction cardiomyopathy (NCCM)

Additional diagnosis *

Danon disease

Friedreich ataxia

Barth syndrome

Duchenne muscular dystrophy

Noonan syndrome

Pompe disease

None of the above

Required

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