National Kidney Foundation Advocacy Application

Basic Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postal Code

Phone

Personal Information

Gender identification

Date of Birth

Race

What's the highest level of school you have completed, or the highest degree you have received?

Connection to Kidney Disease

What is your current connection to kidney disease?

Type of Connection

Dialysis Type

What type of transplant did you receive?

Professional Category

What is the cause of your kidney disease

In the past were you any of the following? (Select all that apply)

Advocacy Experience

Are you a current or former member of an NKF Board of Directors or Medical Advisory Board?

YesNo

Are you already involved with the National Kidney Foundation (NKF) in other ways?

YesNo

If so, how are you involved?

Do you have experience with policy/advocacy activities?

YesNo

If yes, please explain what you have done in the past:

Do you have existing relationships or have you volunteered with legislators at the state or federal level?

YesNo

If so, could you please provide their name(s) and title(s):

Are you involved with any community organizations, particularly with policy or political advocacy?

YesNo

If so, which ones and what have you done in the past?

Would you do any of the following:

	Yes	No
Meet with Legislators and/or testify before legislative bodies
Submit Letters to the Editor and/or speak to the media
Attend events (Kidney Patient Summit, local galas, community program events, etc.)
Participate in NKF advocacy productions (ex. articles, videos, etc)

If someone encouraged you to apply for NKF's Kidney Advocacy Committee, please type their name(s) here.

Bio and Photo

Tell us about yourself - submit a bio detailing your journey with kidney disease, living organ donation, transplantation, experience as a caregiver or provider. Please feel free to detail any relevant professional or advocacy experience (1 -2 paragraphs).

Submit a Photo

Contact Information