IGA Nephropathy Foundation of America

Name *

Street

City

State/Province

ZIP / Postal Code

Mobile #

Home #

Email Address *

1. Date of Birth *

2. What is the highest degree or level of school you have completed? *Some high school, no diplomaHigh school graduate, diploma or the equivalent (for example, GED)Trade/technical/vocational trainingAssociate degreeBachelor’s degreeMaster’s degreeDoctorate degree

3. How long ago were you diagnosed with IgA Nephropathy? *Within the last 1-2 yearsWithin the last 3-5 years6-9 years10 years or longer

4. Which best describes you: *Someone living with IgA NephropathySomeone caring for someone with IgA Nephropathy (If you are a caregiver, please answer the next few questions based on the person who has IgA Nephropathy)Other

Other

8. Tell us a little bit about yourself and how you first learned you had IgA Nephropathy? *

9. Please describe how you think you can make a positive difference for other patients or caregivers facing IgA Nephropathy (Please explain in a few paragraphs, give examples of your experience managing IgA Nephropathy, any challenges, and how that might help others)? *

10. How easy or difficult is it for you to explain IgA Nephropathy to people unfamiliar with the condition? *EasySomewhat difficultDifficultVery difficult

11.What do you think people misunderstand most about IgA Nephropathy? How would you help educate them? *

12.Tell us a little about your recent leadership experience either through a job or as a volunteer? Did this involve helping to educate or engage others around a particular cause? Please explain. *

13.Which of the following activities interests you most? (Please select your top 3) *Offer peer supportLead a local support groupRaise awareness and/or educate people about the conditionHelp with community outreach and/or partner with local nephrology care providersPromote IgA Nephropathy Foundation effortsHelp with fundraisingAttend SPARK, the IgA Nephropathy Foundation’s annual meeting for patients and caregivers to learnthe latest information about the condition and build relationshipsOther

Other

14.Are you willing to travel to SPARK? *YesNoDepends where it is

15.What amount of time are you comfortable giving to the Ambassador Program? *2-3 hours a week4-6 hours a week7-10 hours a weekOther

Other (feel free to note, hours available, certain times of the year when you may have more time available, etc.)

16. Are you interested in applying to become a Co-Chair of the Ambassador Program? *YesNoUnsure, but I'd like to receive more info

Ambassador Program Application

IgA Nephropathy Foundation Ambassador Program Application

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