Interstitial Cystitis Association (ICA) Interest Form

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Thank you so much for your interest in connecting with the ICA! As the only national nonprofit patient advocacy organization serving the interstitial cystitis/bladder pain syndrome community in the U.S., we know the work we do can only be accomplished with the support of our stakeholders. Please take a moment to fill out this form and let us know how you would like to engage with us.

Email *

Your First Name: *

Your Last Name: *

I am a(n) (check all that apply): *

Healthcare Provider

Researcher

Patient

Friend or Family Member of a Patient

Industry Representative (e.g., Employee of a Pharmaceutical Company)

Other:

Required

I am interested in (check all that apply): *

Donating to the ICA

Receiving ICA communications (e.g., monthly newsletters)

Volunteering as a member of the ICA's Ambassador Program

Ordering ICA materials (e.g., provider prescription pads, restroom access cards)

Facilitating a virtual webinar as part of the ICA's Expert Speaker Series

Becoming a corporate partner

Obtaining assistance with study recruitment (I am a researcher)

Being listed on the ICA's healthcare provider registry

Learning more about serving on the Board of Directors

Learning about serving on the Medical Advisory Council (I am a health professional)

Other:

Required

Is there anything else you'd like us to know?

Send me a copy of my responses.

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