Dialysis Patient Citizens: Survey - Become a DPC Patient Ambassador

Become a DPC Patient Ambassador

Please complete the following form. Allow 4-6 weeks for a decision. We will contact you by phone to let you know if you have been selected.

1.

Name and Address Information

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

If you respond and have not already registered, you will receive periodic updates and communications from Dialysis Patient Citizens.

Remember me. What's this?

2.

Question - Not Required - Dialysis Center Name and Address

3.

Question - Not Required - Dialysis Modality

4.

Question - Not Required - Dialysis Days/Times

5.

Question - Not Required - Do you work?

6.

Question - Not Required - If yes, full time or part time? Full Time
Part Time

7.

Question - Not Required - Are you willing to travel by plane?

8.

Question - Not Required - Please give a detailed description of your experience in the following areas, or paste a current resume into the field below -- Educational background, political/advocacy/public speaking experience, writing experience, dialysis community involvement, fundraising experience.

9.

Question - Not Required - Please tell us why you would like to be a Patient Ambassador.