Lupus Buddy Program Survey Form
The Lupus Buddy Program is an initiative of the Lupus Foundation of Northern California. More information can be found on LFNC.org. LFNC treats personal and medical information with strict confidentiality and reserves the right to share this information internally and with its Buddy Program managers and coordinators who follow the same strict policy.
Full Name *
Phone: *
Email: *
Street Address *
City, State, Zip
Gender *
Age (in years) *
Date Diagnosed with lupus *
(please enter '1' for day if you do not remember the exact date - month and year are sufficient)
MM
/
DD
/
YYYY
Type of Lupus You Have *
such as SLE, nephritis, etc.
Do you consider yourself (please choose one) *
Are you Interested at this time in this program?
Clear selection
What is the one thing you would most want out of the Buddy Program?
How much time per month (in hours) would you be willing to invest in this program?
Do you have any concerns about this program?
We would like to reiterate that strict confidentiality governs all data sharing within this program.
Would you like to be a mentor, a mentee, or a buddy?
What mode of contact would prefer with a potential match?
Check all that apply. For all types of contact, the participant is responsible for expenses that may be incurred (e.g. gas to drive, texting or internet charges, etc.)
May we share the information you have given us, as appropriate, with your potential match? *
What is the one thing you have most to offer to this program?
What is the one thing you hope most to learn from this program?
Would you like to volunteer your time to administer this prorgam?
Clear selection
Are you interested in this program at this time? *
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