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REBUILD - Advisor Team Member Application

Thank you for your interest in joining the REBUILD Advisor Team!

Responses to the following questions will be used to assemble a diverse team of patients and caregivers with lived experience of serious limb injury and treatment decision-making (including limb salvage and amputation).
1.Your name (first and last):(Required.)
2.Your e-mail address:(Required.)
3.Your phone number:(Required.)
4.Preferred method of contact:(Required.)
5.Your mailing address:(Required.)
6.Please select the race(s) for which you self-identify.(Required.)
7.Are you Hispanic or Latino/a?(Required.)
8.Please indicate your gender.(Required.)
9.What is your birth date?(Required.)
10.Current occupation:(Required.)
11.Are you involved in any of the following community groups, clubs, or organizations (select all that apply)?(Required.)
12.We will offer both in-person and virtual meeting options. Which format do you anticipate using most often? (You may switch between formats as needed.)(Required.)