General Information

Name:
Address:
City:	State:
Zip:
Country:
Occupation:
ICQ #:

 

Contact Information

Phone Number:
Email Address:

 

 

Personal Information

I am interested in TARA because: I have Takayasu's Arteritis My child has Takayasu's Arteritis a relative has Takayasu's Arteritis Other reason, I'll explain in comments

 

 

Are you fluent in any foreign language(s)? If so, which one(s)?

 

 

Time Commitment

How many hours a month would you be willing to contribute?
1-3     3-6
6-10   10-15
15-20 20+
 

Specific examples of where you are interested in helping:

 

Which of the our goals seems most interesting to you?
Medical Research Conferences

Public Awareness Education

Fundraising

 

Would you be interested in participating in our Keep-in-Touch program? Your email address will be given out to others in your area for networking.
Yes No

 

Additional Comments

Please enter comments below: