Thank you for your interest in WDA's Peer-Led Virtual Support Group

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1. Today's Date (Required.)

Date

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2. Please enter your full name (Required.)

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4. Please provide your contact number (Required.)

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5. State or country that you will be joining from

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6. This group is intended for those with Wilson Disease. Please confirm you are a patient or caregiver/ close relative of somebody with Wilson disease: (Required.)

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7. Which Wilson Disease Virtual Support Group meetings would you like to attend? (Please select all applicable options for 2026) (Required.)

Release and Waiver of Liability

Wilson Disease Association Peer-led Virtual Support Group Participation

As a group participant, I hereby consent to participation in a Peer-led Virtual Support Group. Wilson Disease Association will provide monthly group sessions at no cost to Participants.

The Group facilitator is currently designated as Carly Albinder, LCSW, OSW-C, Wilson disease patient, WDA member and social worker. Groups are subject to have co-facilitators and guest speakers.

I understand that these group sessions are for social support only and that none of the information I disclose will be shared with my healthcare providers for healthcare treatment purposes. I further understand that, in the event that I require medical attention, it is my responsibility to directly contact my physician’s office (or, in the event that I need immediate medical assistance, to call 911). Furthermore, these group meetings will not be used to diagnose or treat Wilson Disease in any capacity. Facilitators and participants do not prescribe medication or treatment in any capacity. Please consult your physician for such matters.

I understand the group facilitator will instruct other participants to keep information shared by other participants confidential; however, I understand that other participants may not keep my information confidential.

I further understand that in the event that group facilitator is concerned that I may engage in self harm or cause harm to others, group facilitator may be obligated to disclose this information to appropriate authorities.

I understand that participation in group sessions is voluntary, and I hereby consent to my participation in the group sessions. I acknowledge and agree that my participation in the group sessions may involve some risk of injury or reputational harm and that I have read and agreed to the “Rules of the Road” for participation that are included below. I assume full responsibility for all risks related to my participation.

Release, Waiver of Liability and Indemnification:

I, as Participant if 18 years or older, hereby release Wilson Disease Association, its subsidiaries and affiliated entities, and their respective past, present, and future directors, officers, employees, and agents from any liability, claims, demands or causes of action for any injury, including breach of privacy or reputational harm, arising out of or connected with my participation in the Group sessions. I also acknowledge and agree that I will indemnify Wilson Disease Association for any third party claims that may occur as a result of my violation of the “Rules of the Road.”
Terms of Use ("Rules of the Road")

Wilson Disease Association Peer-led Virtual Support Group Terms of Use (“Rules of the Road”)

By participating in an online support group facilitated by Wilson Disease Association (WDA), please note you are agreeing to the following:

WDA encourages you to participate in open discussions, share your experiences, ask questions and inquire about WDA through our public social media communities, including online support groups (e.g., Teams, Facebook, Twitter, YouTube, LinkedIn, Blog). We reserve the right to monitor our social media communities to ensure any shared content is appropriate.

Please note that any information available through our social media communities, including online support groups, should not be considered medical advice and does not replace a direct consultation with a health care professional.

Please recognize that anything shared online is available to the public. Please use caution when sharing medical information on any of the WDA’s social media communities, including online support groups, and never disclose personal identifiable information (including but not limited to: your location, medical record number, financial information, other private information).

Please remember that you are responsible for the content you share and all activity that occurs under your social media account or in any online support group. You agree to the following while using or engaging with WDA’s social media communities, including online support groups.
• You agree to not misrepresent yourself or take on the identity of someone else.
• You agree to not use any of the WDA social communities, including online support groups, for personal attacks, defamation, harassment, spam, offensive content, aggressive behavior, or illegal activities.
• You agree not to share content that is illegal, obscene, defamatory, threatening, unlawful, disruptive, profane, harassing or abusive.

Recording of Peer-led Virtual Support Group meetings by any party is prohibited, as is the use of AI note takers in any capacity.

WDA reserves the right to monitor, prohibit, restrict, block, suspend, terminate, delete or discontinue your access to any social community at any time, including online support groups, without notice in its sole discretion.

Opinions and views expressed by individuals on the WDA social media communities, including online support groups, are not necessarily those of WDA, its employees, staff or board members.
WDA Privacy Policy

The WDA has a strong commitment to privacy and values your trust. This privacy statement applies to all information collected through your communications with the WDA or through your participation in its events and programs, whether in electronic, written or oral form (“Personal Information”).

The WDA will not sell, trade or share your Personal Information with any other entity; provided that the WDA may share Personal Information with its service providers and program volunteers, and as may be required by law. The WDA will not share Personal Information with third parties for marketing purposes.

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8. By typing my name below in the box below, I hereby confirm that I have read fully and understand the above statements, including the Release and Waiver of Liability and the “Rules of the Road" and consent to their terms. (Required.)

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9. (Optional) Please provide an emergency contact in the event that the group leader has any concerns.

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10. How did you hear about our virtual support group?

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