If you are 16-35 years old please print out, complete and return the following questionnaire. If you have already been tested let your friends know.

1. Is either of your parents of Ashkenazi Jewish descent?
Yes( ) No ( )

2. Testing is available currently on Sundays at the Wolper Hospital.
Is this a suitable location and time?
Yes( ) No ( )

If NO Where and when would you prefer to be tested?
University ( )
On weekend ( )
Hakoah Club ( )
Weeknight ( )
During term ( )
During holidays ( )
Other ( )
Specify _______________

3. Because testing is very expensive the community is subsiding part of the cost. Testing for full-time students and unemployed may be partially or wholly subsidised. Is this important to you?
Yes( ) No( )

(The regular charge is $40.00-$120.00 per test depending on program chosen.)

4. Other genetic diseases such as cystic fibrosis, Canavan disease, and Fanconi anaemia can also be tested for at the same time as for Tay-Sachs disease. We have printed detailed information sheets which we can send to you.
Yes Please ( ) No Thank You ( )

Please complete your details.

Name: ______________________________ Date of Birth:_____________

Address: _______________________________

Contact phone number:_________________

Email address: ______________________

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Please print out, then mail or fax your completed form to:

Anne Proos
Kolling Institute of Medical Research
RNS Hospital, St Leonards NSW 2065, Australia
Ph: +61-2.9926-8899 Fax: +61-2.9926-8484
Email: aproos@med.usyd.edu.au