LSN Membership Application

Membership Application

If you have any questions or problems completing this form, please email Liposarcoma Support Network: support@liposarcomasupport.org
All information provided will be kept strictly confidential and is for Liposarcoma Support Network (LSN) only. We are committed to protecting the privacy of our members. Any data or information that we share in any way is de-identified to protect confidentiality. LSN is a program of The Life Raft Group.
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
I am a:*
If other, please specify:*
Patient Name*

First NameLast Name
The patient is my:*
If 'other' please specify:*
I am interested in:

Fundraising ActivitiesBecoming a Mentor (Mentors support liposarcoma patients throughout their journey.)Support GroupsVolunteeringOther
Which subtype of liposarcoma were you diagnosed with?*
How did you hear about Liposarcoma Support Network? Choose all that apply.

Another Liposarcoma Support Network memberThe Liposarcoma Support Network Facebook pageInternet searchDoctorOther
If other, please specify*
Email address*
example@example.com
US Country code is 1. Look up country codes here.
Phone Number*

Country CodeArea CodePhone Number
This phone is my*
Preferred Method of Contact*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
WhatsApp Number*
Skype ID*
Preferred time to contact*
Please indicate time zone*
Please verify that you are human*
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