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WAI Community Leader Application
Basic Information
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1.
What is your first name?
(Required.)
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2.
What is your last name?
(Required.)
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3.
What is your email address?
(Required.)
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4.
Please re-type your email address for confirmation.
(Required.)
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5.
What is your 5-digit zip code?
(Required.)
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6.
What type of MS have you been diagnosed with?
(Required.)
Primary-progressive MS (PPMS)
Relapsing-remitting MS (RRMS)
Secondary-progressive MS (SPMS)
Clinically Isolated Syndrome (CIS)
I don't know
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7.
When were you diagnosed with MS? (Month and Year)
(Required.)
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8.
What is your age range?
(Required.)
Younger than 25
25-39
40-59
60 and older
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9.
Which region are you interested in leading?
(Required.)
Northeast (includes Boston; New York City; Philadelphia; and Washington, DC)
South (includes Atlanta, Dallas and Miami)
Midwest (includes Chicago, Detroit, and Indianapolis)
West (includes Los Angeles)
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10.
Please enter the link to your Facebook profile.
(Required.)
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11.
Please enter the link to your Instagram profile.
(Required.)
