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Required Fields
Contact Information
First Name
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Last Name
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Email
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Confirm Email
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Phone
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Address
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Address 2
City
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State/Province
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Zip/Postal Code
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Country
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Birth Date [mm/dd/yyyy]
mm/dd/yyyy
mm/dd/yyyy
Do you have cystinosis?
Yes
No
* Do you have cystinosis? is required.
How old were you when diagnosed with cystinosis?
*Required
Education Experience (please choose highest level):
Currently attending high school
High school graduate
Currently attending college
Completed undergraduate degree
Currently attending graduate school
Completed graduate school
* Education Experience (please choose highest level): is required.
Will you be able to commit to 1-2 monthly phone/video conference meetings?
Yes
No
* Will you be able to commit to 1-2 monthly phone/video conference meetings? is required.
Tell us about a personal accomplishment you are most proud of
Tell us about your experience working on a group project and how the group worked together. What role or action did you take?
Why are you applying for the Adult Leadership Advisory Board?
What types of programs or services would you like to see available to adults with cystinosis?
Based on your cystinosis journey, what insights, experiences, or perspectives do you feel you would bring to the group?
What is your level of experience with social media?
I use it every day, I'm always online
I use it several times a week and create posts/content occasionally
I occasionally use it, but rarely create posts or content
I don't go on social media/don't use any platforms
* What is your level of experience with social media? is required.
Have you ever managed a social media account aside from your own? If yes, please specify
Yes
No
* Have you ever managed a social media account aside from your own? If yes, please specify is required.
If yes, above, please specify other social media accounts you have managed
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