Registration Form
  Personal Information
Please select an Id you can easily remember. Examples: Name: John Smith UserId: jsmith1960
Name:William B Hartsfield UserId: willyB
User Id
  User Information
First Name
Last Name
E-Mail Address
-- Ext 
Fax Number
Pager Number
Enter Title if not in list
  Please choose your type of organization from the list below. Once your type is selected, select your organization. If you can not find your organization, please select "Enter New Organization" in the "Organization" drop down box."
Type of Organization
New Organization Name  
Zip Code
  Access Required
      Choose this if you are a reporter of Birth Defects for your organization
  Public Health Workers Only
    (Only check this box if you need Admin privileges for your district. If you need regular UpToDate access, please visit -!uptodate.login)
    (Only check this box if you need Admin privileges for your region. If you need regular (grantee) Car Seat Monthly Reporting access, please visit -!carseat.login)
  Supporting Information for Access
Are you the only person from your organization using SENDSS ? Yes No Unknown
Has your organization had formal SENDSS training? Yes No Unknown
How did you hear about SENDSS?
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