* required information Volunteer Interest Survey Form  Contact Information Please complete the contact information and the survey below to indicate your areas of volunteer interest. Check only those areas that you have a strong interest in. We encourage volunteers to focus his/her energy into one role that they are passionate about – if they want to do more, GREAT. If you would like to review a complete hard copy of all the volunteer opportunities and read a printable copy of the survey first, click here! Affected Individual: Yes No Title: -- please make a selection --AdmiralAmbass. & Mrs.AmbassadorBGENBishopBishop and Mr.Bishop and Mrs.Brotherc/oCantorCantor and Mr.Cantor and Mrs.Capt.Capt. and Mrs.CDRCdr.Chap.Chaplain & Mrs.Cmdr.CMSGTCol.Col. and Mrs.CommissionerCWO4DeaconDr.Dr. & Rev.Dr. and Dr.Dr. and Mr.Dr. and Mrs.Dr. and Ms.Dr. and Rev.Drs.ElderEstate ofFatherFr.GeneralH.R.H.Hon.JudgeLt.Lt. Cmdr.Lt. Col.MajorMessrs.MissMonsignorMotherMr.Mr. and Mrs.Mr. and Ms.Mrs.Ms.MSG.Mss.Prof.Prof. and Mr.Prof. and Mrs.Prof. and Ms.RabbiRabbi and Mr.Rabbi and Mrs.Rep.Rev.Rev. and Mr.Rev. and Mrs.Rev. Dr.Rev. Dr. & Mrs.Rt. Rev.Rt. Rev. & Mr.Rt. Rev. & Mrs.SenatorSenator & Mrs.Sgt.SisterSr.TheThe Hon.The Hon. & Mr.The Hon. & Mrs.The Rev. Deacon First Name:* Last Name:* Suffix/Degree: -- please make a selection --NONE (n/a)BS, RNBsc PhD ChBsc, PhdCCC-SLPCFSCMP, CMMCPIMCPNPDCDDSDDS, MDODPMDVM, MDVM, PhDEsqFAAPFICSFRCPFRCPCFRCSFRCSE, FRAIIIIIIVJRLPNMScMAMBMB,ChBMBAMBA, MPHMBBS, FRCPMDMD, FAMD, FACSMD, FRMD, FRCPMD, MACGMD, MPHMD, PAMD, PCMD, PhDMPAMP-CMPHMPH, RNMSMS, PAMSPHOTROTR/LOTPAPACPharm DPhDPhD, DABPhD, FCPhD, MBAPhD, MDProf. MDPsyDPTRMARNRN, CCRCRN, CPNPRN, CPNPRN, NPRNC, NPRNPSrVP Address Line 1:* Address Line 2: City:* State:* -- please make a selection --AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaF.S. MicronesiaFloridaGeorgiaGuam HawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingNot in USA Province: ZIP/Postal Code:* Country:* -- please make a selection --AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Email:* Cell Phone: Phone:* Business Phone: Other Affected Loved Ones (names, birthdates, genders, relationships to you and whether or not they are deceased): Birth Date:* (mm/dd/yyyy) How did you hear about us?:* -- please make a selection --BillboardBlogChatroomDoctorEmailFamilyFriendInternet AdvertisingLogo MerchandiseMagazineHealth Care OrganizationHealth Care ProfessionalMessage BoardNewspaperOtherRadioResearcherSearch EngineTVUMDF MemberWebsite Opt in: Yes! I would like to receive further information via email about the United Mitochondrial Disease Foundation. PLEASE SELECT YOUR AREA(S) OF INTEREST (for descriptions, visit www.umdf.org/volunteeropps) Education: Grand Rounds Patient/Family Meeting with Mitochondrial Specialist Mini-Symposium or Regional Symposium Case Studies Medical Schools Physician Outreach and Educator Campaigns IEP Liaison Support: Support Liaison UMDF Activity/Meeting Organizer/Host Patient/Family Meetings with a Speaker Social Networking Liaison Special Events/Fundraising: Energy for Life Walks Third Party Events (galas, golf outings, etc) Advocacy: Governmental Advocacy Development: Identifying individual, foundations or corporations that may be able to support UMDF financially Personally supporting the UMDF at some level financially Working with UMDF staff to identify programs and projects Working with UMDF staff to brainstorm innovative ways of securing funding What choice(s) interest you the most? Why?: Please describe in more detail how you might help based on your selections above: Are there any other ways you could assist the UMDF in fulfilling its mission?: