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Thank you in advance for helping us put together a moving and powerful Survivors Celebration for you and the other participants at our 2017 Kansas City conference. Please answer the questions below and follow the instructions for submitting a photo. We look forward to seeing you on October 14.

Remember, at AAMDSIF we believe a survivor is anyone who is living with and coping with impact of a bone marrow failure disease. This includes patients and caregivers.

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* 1. Please provide your name and contact information. We may follow up with you about your information if we have questions about the information you provided.

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* 2. If someone other than the patient is filling out this survey, please provide the patient's name and city/state:

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* 3. What is the "approximate" diagnosis date of the patient? (only used to define years of survivorship)

Date

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* 4. What is/was your occupation?

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* 5. In a few words, describe a personal accomplishment you are most proud of.
(examples: I won 1st prize at the County Fair; I built a 19 ft. sailboat; I ran the Rock and Roll Marathon; I have read every Shakespeare play; I conquered my fear of heights with a hot air balloon ride)

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* 6. Think about your next great vacation. Where do you want to go? What do you want to do/see? (example: I want to go on an Alaskan cruise and see humpback whales jumping from the water)

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* 7. What one quality best describes someone you would call a "Survivor"?

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* 8. In those moments when you need inspiration or are having a bad day, what words/sayings/quotes inspire you most? If you know who said it/wrote it please include that too.
(This can be something of your own, from someone you know, or from someone famous)

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* 9. We would like to use your comments and photos for our Survivors Celebration and possibly other places to help raise awareness and support for AAMDSIF's work fighting bone marrow failure diseases. Please authorize the use of your information. (Please select one)

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* 10. Please send in a photograph or two of you (alone or with family or friends) that celebrates your life. Send the photo(s) to conference@aamds.org. If you have any questions about this survey or sending in a photo, contact us directly at (800) 747-2820. Your photo may be used as part of a presentation at the Survivors Celebration.

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