SURVEY


Name:

City/State:

Email:

Phone:

Preferred method of contact:



Are you here for:




Age:







Have you been to a meeting?:


If so was it helpful and what would you liked included next time?:

How often would you like to meet?:




Best Day/Time to meet?

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Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1-3: 1-3: 1-3: 1-3: 1-3: 1-3: 1-3:
2-4: 2-4: 2-4: 2-4: 2-4: 2-4: 2-4:
5-7: 5-7: 5-7: 5-7: 5-7:

6-8: 6-8: 6-8: 6-8: 6-8:


What are you looking for in a support group?

Friendship/Support:

Community Awareness:

Medical Community Education:

Fundraising for Reseach:

Advocay:

Other:


Would you like to help? Tell us about yourself and what you'd like to do!:


Fill out as much or as little as you’d like! We will NOT share any information collected. All information collected is used only to improve the support group and help its members.

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