Tell us about yourself

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. What is the best phone number to reach you?

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* 5. What is your mailing address?

Your Voice is POWERFUL!

You may not realize it, but your voice and your personal LBD experiences are powerful tools in the fight against LBD. You are true experts about the impact of LBD on everyday life. Together, we can drive change that helps LBD families today and in the future!

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* 6. Which of following activities would you be interested in? (Please check all that apply)

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* 7. How you can help advance the cause of LBD (Please check all that apply)

  No interest Some interest High interest
Sharing my LBD experience with researchers and other research stakeholders
Sharing my LBD experience with policy makers and legislators
Public speaking opportunities
Receiving training to be more effective as an LBD advocate
Demographics

LBD does not discriminate. And it affects us all in different ways based on our age, race/ethnicity, education, access to care and services, etc. So, we NEED a very diverse group of disease advocates. Please tell us about yourself so we can engage all types of people affected by LBD.

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* 8. What is your race/ethnicity?

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* 9. What is your highest level of education?

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* 10. What is your community type?

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* 11. What is your age?

About You and LBD

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* 12. What is your connection to LBD?

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* 13. If you are a family member or friend of the person with LBD, which of the following best describes you?

We appreciate your interest and we look forward to sharing opportunities with you to get involved in the future!

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