Arthritis Foundation JA Committee Interest Form

Arthritis Foundation JA Committee Interest Form

FIRST NAME: LAST NAME: MI:

OCCUPATION/COMPANY:

ADDRESS:

CITY/STATE/ZIP:

PREFERRED PHONE: ( )________________ ¨ Home ¨ Work ¨ Cell OTHER ( )__________________¨ Home ¨ Work ¨ Cell

PREFERRED E-MAIL: ________________________________________________________________________________________

Connection to Arthritis?

¨ Self ¨ Sister ¨ Brother ¨ Friend ¨ Son ¨ Daughter ¨ Other________________________________________

Type(s) of arthritis / rheumatic disease that affects you or your family________________________________________

If Child(ren) with JA – NAME: ___________________________________ Current Age: ______ Birthdate: _______

NAME: ___________________________________ Current Age: ______ Birthdate: _______

How long have you or your child been diagnosed? (if applicable)

What specific areas of expertise will you be able to bring to the JA committee? (For example: connections in community, marketing/PR, event planning, etc.).

Please share with us ideas/suggestions to grow the JA community in our market?

I have volunteered with Arthritis Foundation:

¨ JA Chair

¨ Advocacy Program

¨ JA Family Days

¨ JA Conference

¨ JA Camp

¨ Other _____________________________________

¨ Walk to Cure Arthritis / Jingle Bell Run

¨ Event Day

¨ Team Captain

¨ Planning Committee