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NMO Patient Advocacy Council Application
Confidential Application for Council Membership- Submitted on a voluntary basis
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I am completing this application on a voluntary basis.
Name:
Your answer
Email:
Your answer
Phone:
Your answer
Home Address:
Your answer
What is your role in the NMO community (please choose all that apply)?
Patient
Caregiver
Other:
Clear selection
Are you able to commit to a minimum one year Advocacy Council term?(In year one, you may anticipate an average of 3-6 hours per week.)
Yes
No
Being a patient advocate is largely a communications position. In which ways are you most comfortable communicating with patients and caregivers? Please check all that apply:
Social Media
Phone calls
Email
All of the above.
Which of the following social media and other platforms do you currently use? Check all that apply:
Facebook
Instagram
Twitter
LinkedIn
Zoom
Teams
Webex
Other:
Are you interested in hosting a Regional NMO Support Group?
Yes
No
What languages do you speak?
Your answer
Please tell us why you are interested in becoming a representative of The Guthy-Jackson Charitable Foundation's Advocacy Council. Thank you. (250 words or less)
Your answer
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