The National Kidney Foundation’s Patient Advocacy Initiative

Turn on the power of People Like Us!

“People Like Us” is the strongest, most effective advocacy group of people with chronic kidney disease, organ donors and transplant recipients. Join “People Like Us” today and make your voice heard on issues related to kidney disease, transplantation and donation. For more information, please visit our web site (www.NKFpeoplelikeus.org); e-mail us at peoplelikeus@kidney.org; or call us at (800) 622-9010. Also, access the Take Action Network.

Printable form (PDF* 76kb download)

First Name:

Last Name:

Organization (if applicable):

Address:

Address 2:

City:

State/Province:

Zip/Postal Code:

Country:

E-mail:

Home Phone:

Work Phone:

Fax:

Please complete the following about yourself. I am a:

Dialysis Patient
         Peritoneal
         Hemodialysis
        How long?

Chronic Kidney Disease Patient (not on dialysis/not transplanted)

Transplant Recipient
        Organ(s) Received:
        Date transplanted:
        I received a transplant from a:
                 Deceased Donor
                 Living Donor.
                He/she is my:
                                      (ie, husband, wife, sister, friend, etc.)

Living Donor
        Organ Donated:
        Date transplanted:
                Recipient is my:
                                          (ie, husband, wife, sister, friend, etc.)

Family Member of a: (Check all that apply)
        Transplant Recipient
        Dialysis Patient
        Kidney patient (not on dialysis)
        Living Donor

Donor Family Member (family member of a deceased donor)

Please indicate any personal or professional skills, interests, relevant experience or leadership positions held.

I’d also like to enroll in the following NKF programs.
Membership is free!
(Check appropriate councils)

	The Patient & Family Council (PFC) works to ensure that kidney patients receive the best care possible and promotes patient and family involvement in life enhancing programs. (visit www.nkfkidneypatients.org for more information)
	The transAction Council works to ensure a better quality of life for transplant recipients by providing information and programs in education, fitness and research. (visit www.transplantrecipients.org for more information)
	The National Donor Family Council (NDFC), the “Home for Donor Families”, works to increase the sensitivity and effectiveness of the organ recovery process, and allows families to grieve and honor their loved ones. (visit www.transplantrecipients.org for more information)
	Check here if you are interested in receiving information for living donors and potential donors. (visit www.livingdonors.org for more information)

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