LBDA Volunteer Application Tell us about yourself Question Title * 1. What is your first name? Question Title * 2. What is your last name? Question Title * 3. What is your email address? Question Title * 4. What is the best phone number to reach you? Home Work Cell Question Title * 5. What is your mailing address? Street 1 Street 2 City State Zip Code Country 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! Question Title * 6. Which of following activities would you be interested in? (Please check all that apply) I am interested in being a support resource to LBD Families by facilitating an in-person support group, moderating an online support group, or offering peer support by phone or email I can raise public awareness by sharing my personal experiences with the media I can inform thought leaders about the needs of LBD families by sharing my personal experiences I can organize a fundraiser I am interested in sharing my professional skills through service on committees I want to donate in-kind professional services I am interested in serving on LBDA's Board of Directors Question Title * 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 researchers and other research stakeholders No interest Sharing my LBD experience with researchers and other research stakeholders Some interest Sharing my LBD experience with researchers and other research stakeholders High interest Sharing my LBD experience with policy makers and legislators Sharing my LBD experience with policy makers and legislators No interest Sharing my LBD experience with policy makers and legislators Some interest Sharing my LBD experience with policy makers and legislators High interest Public speaking opportunities Public speaking opportunities No interest Public speaking opportunities Some interest Public speaking opportunities High interest Receiving training to be more effective as an LBD advocate Receiving training to be more effective as an LBD advocate No interest Receiving training to be more effective as an LBD advocate Some interest Receiving training to be more effective as an LBD advocate High interest DemographicsLBD 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. Question Title * 8. What is your race/ethnicity? White Non-Hispanic/Caucasian Hispanic Black/African American Asian/Pacific Islander Native American/Alaskan Native Two or more races Other (please specify) Question Title * 9. What is your highest level of education? Grade school High school diploma Some college College graduate Question Title * 10. What is your community type? Urban Suburban Rural Remote Question Title * 11. What is your age? Under 18 (will need parental approval to volunteer) 18-30 30-39 40-49 50-59 60-69 70-79 80 or older About You and LBD Question Title * 12. What is your connection to LBD? I have LBD Caregiver/Care Partner Other family/friend of person with LBD Healthcare professional Question Title * 13. If you are a family member or friend of the person with LBD, which of the following best describes you? Primary caregiver Not the primary caregiver Former caregiver We appreciate your interest and we look forward to sharing opportunities with you to get involved in the future! Done
