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Kidney Basics
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National Kidney Foundation Advocacy Application
Basic Information
First Name
MI
Last Name
Address Line 1
Address Line 2
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
Email
Phone
Personal Information
Gender
Please select...
Male
Female
Other
Do Not Wish to Answer
Date of Birth
Please use format DD/MM/YYYY
What is your race?
Please select...
American Indian or Native Alaskan
Asian American
Black or African American
Do Not Wish to Answer
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
What's the highest level of school you have completed, or the highest degree you have received?
Less than high school degree
High school degree or equivalent (e.g. GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Post-Graduate degree
Which of the following category best describes your employment status?
Employed, working full-time
Employed, working part-time
Not employed, looking for work
Not employed, NOT looking for work
Retired
Disabled, not able to work
Connection to Kidney Disease
What is your current connection to kidney disease?
Please select...
I am a kidney patient
I am a family/friend of a kidney patient
I am a living donor
Other
I am a healthcare professional
Type of Connection
Please select...
I am at risk for kidney disease
I have CKD Stage 1 or 2
I have CKD Stage 3
I have CKD Stage 4 or 5 and not on dialysis
I am on dialysis
I am a transplant recipient
I have kidney cancer
I have kidney stones
A family member/friend is at risk for kidney disease
A family member/friend has CKD 1 or 2
A family member/friend has CKD 3
A family member/friend has CKD 4 or 5 and is not on dialysis
A family member/friend is on dialysis
A family member/friend is a transplant recipient
A family member/friend is a living donor
A family member/friend is a deceased donor
A family member/friend is a deceased patient
A family member/friend has kidney cancer
A family member/friend has kidney stones
Dialysis Type
Please select...
Home Hemodialysis
Hemodialysis
Nocturnal Hemodialysis
Peritoneal
What type of transplant did you receive?
Please select...
Living Donor
Deceased Donor
Professional Category
Please select...
Dietitian
Fellows
Nurse
Nurse Practitioner
Nurse Technician
Pharmacist
Physician
Physician Assistant
Resident
Scientist
Social Worker
Student
Technician
Other
What is the cause of your kidney disease
Please select...
C3G
Diabetes
High Blood Pressure
Glomerulonephritis
Polycystic Kidney Disease (PKD)
Lupus
Alport's Syndrome
IGA Nephropathy
FSGS
In the past were you any of the following? (check all that apply)
Hemodialysis Patient
Peritoneal Dialysis Patient
Home Hemodialysis Patient
Transplant Recipient
None of the Above
Advocacy Experience
Why do you want to be part of NKF's advocacy and patient engagement efforts? What specific strengths would you bring to your role as an Advocate?
Are you a current or former member of an NKF Board of Directors or Medical Advisory Board?
Yes
No
Are you involved with the National Kidney Foundation (NKF) in other ways?
Yes
No
If so, how are you involved?
Do you have experience with policy/advocacy activities?
Yes
No
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?
Yes
No
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?
Yes
No
If so, which ones and what have you done in the past?
Would you do any of the following:
Yes
No
Meet with Legislators
Submit Letters to the Editor
Speak to the Media
Testify before agencies or legislative bodies
Attend events
Participate in NKF advocacy productions (ex. articles, videos, etc)
What type of activities are you most interested in?
(Choose all that apply)
Advocacy
Community Outreach/Local Events
Legislation
Patient Advisory roles
Patient Education: Writing/Editing/Development
Policy
Regulatory
Research
Speaking Engagements
If someone encouraged you to apply for NKF's Kidney Advocacy Committee, please type their name(s) here.
Do you know anyone who has experienced any insurance discrimination or job loss due to kidney disease/transplantation?
Self
Others
No
Are you a veteran?
Yes
No
Are you a business owner?
Yes
No
Social Media Involvement
Facebook URL
Twitter Handle
LinkedIn URL
Use this space to share with us any other social media platforms you use or if you have a blog or a website about your kidney disease, donation or transplant journey.
Bio and Photo
Tell us about yourself - submit your official bio. Be sure to include your experiences with kidney disease, donation or transplant and any relevant professional or advocacy experience (1 -2 paragraphs)
Submit a Photo
