*1.In what major metropolitan area do you live, or live near?(Required.)

Atlanta, GA

Austin, TX

Baltimore, MD

Boston, MA

Chicago, IL

Cincinnati, OH

Cleveland, OH

Columbus, OH

Dallas, TX

Denver, CO

Detroit, MI

Houston, TX

Indianapolis, IN

Kansas City, KS

Little Rock, AR

Los Angeles, CA

Miami, FL

Milwaukee, WI

Minneapolis, MN

Nashville, TN

New Orleans, LA

New York City, NY

Orlando, FL

Philadelphia, PA

Phoenix, AZ

Pittsburgh, PA

Portland, OR

Richmond, VA

San Antonio, TX

San Diego, CA

San Francisco, CA

Seattle, WA

St. Louis, MO

Tampa, FL

Washington, DC

Other metropolitan area:

*2.What is your relationship to bone marrow failure disease?(Required.)

Patient

Spouse

Parent of Pediatric Patient

Parent of Adult Patient

Family Member

Friend

Other:

3.What is the primary diagnosis of the patient? Choose all that apply.

Aplastic Anemia

MDS (myleodysplastic syndromes)

PNH (paroxysmal nocturnal hemoglobinuria)

PRCA (pure red-cell aplasia)

Other disease:

*4.May we give your contact information to the AA&MDSIF volunteer organizer in your area?(Required.)

Yes

No

Other (please specify):

*5.Would you like more information about being a volunteer organizer or committee member in your metropolitan area?(Required.)

Yes

No

Other (please specify):

*6.Would you like to learn more about participating as a fundraiser and awareness volunteer for events in your area?(Required.)

Yes

No

Other (please specify):

*7.Please provide us with the following information(Required.)

Name: *

Address:

Address 2:

City/Town:

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:

Email Address: *

Daytime Phone Number:

8.Thank you for taking the time to answer our questions. If you have any additional comments or suggestions, please include them in the space provided.