Biographical Information
Salutation*—Please choose an option—Mr.Ms.Mrs.Dr.Rev.
First Name* Middle Name Last Name*
Email Address*
Street Address*
City*
State*—Please choose an option—AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia
Zip Code*
Primary Phone*
Is the primary phone entered a cell phone?*YesNo
Secondary Phone
Is the secondary phone entered a cell phone?*YesNo
Are you willing to have your contact information shared with fellow Patient Ambassadors?*Yes, you may share my contact information.No, you may not share my contact information.
We encourage Patient Ambassadors to work together. If you are comfortable consenting to sharing your information, we would like to provide your contact information to your fellow Patient Ambassadors in your state or region to help you coordinate. We will not provide any of your information to third parties or anyone outside GOALIFE and the Patient Ambassador program.
Which of the following best describes you?*—Please choose an option—In-Center HemodialysisHome HemodialysisPeritoneal DialysisFamily MemberTransplant RecipientChronic Kidney Disease (Pre-Dialysis)
Dialysis Center Information
Dialysis Center Provider*—Please choose an option—American Renal AssociatesDaVitaDialysis Clinic, Inc.FreseniusGambro HealthcareNorthwest Kidney CentersSatellite HealthcareUS Renal CareOther
Dialysis Center Name*
Dialysis Center Phone Number*
Dialysis Days*MWFTuThSatOther
Interview Questions
What is your educational background?
What political advocacy and public speaking experience do you have?
What sort of writing experience do you have?
Aside from GOALIFE, are you involved in the kidney care community in any other ways?
Is there anything else you are involved in that might be relevant to the Patient Ambassador Program?
Why would you like to be a Patient Ambassador?
Attachments: Here you may attach your resume, CV, or any other documents that might be relevant.
Patient Ambassador AgreementI am a citizen of the United States of America. I will join the Patient Ambassador policy update calls when I am able. If I am not able to join the calls, I will listen to them afterwards. I will send my action reporting forms online by the time they are due even if I am unable to complete the actions. I will communicate with DPC and solicit feedback before I schedule meetings with legislators, hold events, and contact my local media.
Do you agree to these terms? *Yes, I agree to these terms.
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