General Volunteer Interest Form Contact Info: Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Email Question Title * 4. Phone Number Question Title * 5. Address Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Volunteer Info: Question Title * 6. Have you ever volunteered with the MSA Coalition? Yes No Question Title * 7. How much time would you like to volunteer annually? 0-5 hours 5-10 hours 10-15 hours 15-20 hours 20+ hours Question Title * 8. Areas of interest? (Examples are including but not limited to) Fundraising (Example: Host a fundraiser) Finance (Example: Help form the budget) Leadership (Example: Board of Directors position) Advocacy (Example: Write a letter to your elected official) Awareness (Example: Write a blog or share your MSA story) Community Engagement (Example: Patient support groups) MSA Research Development (Example: Grant reviewer) Patient Education (Example: Curate content for webinars) Other (please specify) About you and your MSA connection: Question Title * 9. Why would you like to volunteer for the MSA Coalition? Question Title * 10. What is your connection to MSA? Care partner Patient Former care partner Health care professional (clinician, researcher, scientist) MSA patient family member Other (please specify) Demographics: The MSA Coalition does not discriminate. In an effort to be as accessible and inclusive as possible, it is important for us to understand the diversity of our audience and volunteers. Please tell us about yourself so we can engage all types of people affected by MSA. Question Title * 11. Please select your age range (OPTIONAL) Under 18 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to disclose Question Title * 12. Please select your gender (OPTIONAL) Female Male Transgender female Transgender male Gender non-conforming Non-binary Other Prefer not to disclose Question Title * 13. Please select your ethnicity (OPTIONAL) Asian Pacific/Islander American Indian/Native American Black or African American White or Caucasian Hispanic/Latino Multi-racial Other Prefer not to disclose Question Title * 14. Please select your community type (OPTIONAL) Urban – 50,000 people or more Suburban or urban cluster – between 50,000 and 2,500 people Rural - Under 2,500 people Done
