HDU Board Application
1.
What is your name
2.
What is your age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
3.
What is your gender?
Male
Female
Prefer not to answer
Other (please specify)
None of the above
4.
What is your ethnicity?
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
Multiple race
Other (please specify)
5.
What is your current employment status?
Employed full-time
Employed part-time
Homemaker
Seeking opportunities
Student
Retired
Unable to work
Prefer not to say
Other (please specify)
6.
Where do you live? (State)
7.
What is your phone number?
8.
What is your email address?
9.
W your treatment history with kidney disease? Please check all that apply, and add any notes in the "Other" field *
CKD
Pre-dialysis
in-center hemodialysis
peritoneal dialysis (PD)
home hemodialysis
current transplant
previous transplant
Other (please specify)
10.
How many years you’ve been associated with Kidney Disease?
*
11.
Why are you interested in being on the Home Dialyzors United Board? (1-2 paragraphs) *
(Required.)
12.
What experiences and perspectives would you add as a board member? (1-2 paragraphs)
13.
Check any specific skills you have:
Blogging or opinion writing
Social media
Advocacy
Public speaking
Fundraising
Other (please specify)
None of the above
14.
What other patient groups are you a part of? Check all that apply.
American Association of Kidney Patients (AAKP)
National Kidney Foundation (NKF)
American Kidney Foundation (AKF)
ESRD Networks
Home Dialyzors United
Home Dialysis Central
Other (please specify)
None of the above
15.
How much time do you have to devote to being a board member? *
Less than 1 hour/month
1-3 hours/month
4-8 hours/month
More than 8 hours/month
16.
Is there anything else you would like to share?
Current Progress,
0 of 16 answered
