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* 1. What is your name

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* 2. What is your age

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* 3. What is your gender?

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* 4. What is your ethnicity?

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* 5. What is your current employment status?

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* 6. Where do you live? (State)

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* 7. What is your phone number?

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* 8. What is your email address?

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* 9. W your treatment history with kidney disease? Please check all that apply, and add any notes in the "Other" field *

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* 10. How many years you’ve been associated with Kidney Disease?

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* 11. Why are you interested in being on the Home Dialyzors United Board? (1-2 paragraphs) *

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* 12. What experiences and perspectives would you add as a board member? (1-2 paragraphs)

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* 13. Check any specific skills you have:

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* 14. What other patient groups are you a part of? Check all that apply.

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* 15. How much time do you have to devote to being a board member? *

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* 16. Is there anything else you would like to share?

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