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Apply to be a 1:1 Ambassador
Thank you for your interest in volunteering for United Porphyrias Association's UPA 1:1 program. Please tell us a bit about yourself so we can get started.
UPA 1-1 Peer Support
Name
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non-binary
Prefer not to say
Email
*
example@example.com
Phone
*
Where do you live?
Diagnosis
*
Acute intermittent porphyria (AIP)
Congenital Erythropoietic Porphyria (CEP)
ALAD-deficiency porphyria (ADP)
Erythropoietic Protoporphyria (EPP)
Hepatoerythropoietic porphyria (HEP)
Hereditary Coproporphyria (HCP)
Porphyria Cutanea Tarda (PCT)
Variegate Porphyria (VP)
X-Linked Protoporphyria (XLP)
Undiagnosed
How many times a month could you have calls with patients?
1
2
3
More than 4
What is your availability? On which days and during what times could you contact patients?
I understand and accept that this would be a volunteer position and that I would not receive any payment or compensation in return.
Agree
Yes, I would like to join the United Porphyrias Association to receive news, information and updates. UPA may also contact you for research opportunities related to porphyria and rare disease. Your information will never be shared without your consent per United Porphyrias Association Privacy Policy.
Agree
Submit
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