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1
Name
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First Name
Last Name
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2
Preferred Name
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3
Email
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example@example.com
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4
Address
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Street Address
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State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Australia
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Azerbaijan
The Bahamas
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Botswana
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Cape Verde
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China
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Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
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Denmark
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Dominica
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El Salvador
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Fiji
Finland
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The Gambia
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Guinea-Bissau
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Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Phone Number
Please enter a valid phone number.
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6
Age Range
*
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Please Select
18–24
25–34
35–44
45–54
55+
Please Select
Please Select
18–24
25–34
35–44
45–54
55+
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7
How are you connected to PCOS?
*
This field is required.
I live with PCOS
I support someone with PCOS
I am a healthcare-adjacent professional
I am an educator / advocate
Other (please explain)
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8
Briefly share your PCOS story or connection
*
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9
Why are you interested in joining Teal Impact Corps?
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10
Which statement best reflects your motivation?
I want to contribute to PCOS education and advocacy in a meaningful, consistent way
I want to learn more about PCOS and support others
I am exploring volunteer opportunities
Other (please explain)
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11
What does accountability mean to you in a volunteer role?
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12
Which role are you interested in?
(Note: Selection does not guarantee placement.)
Teal Guides (1–2 hours/month)
Teal Educators (quarterly engagement)
Teal Captains (leadership role)
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13
How many hours per month can you realistically commit?
Please Select
1–2
3–5
6–10
10+
Please Select
Please Select
1–2
3–5
6–10
10+
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14
Which activities interest you most?
*
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Community education
Peer support conversations
Awareness campaigns
Event support
Local outreach
Online engagement
Data/feedback collection
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15
Do you have experience in any of the following?
*
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Community organizing
Public speaking
Facilitation or teaching
Healthcare or public health
Nonprofit or advocacy work
Fundraising
Social media or digital content
Data collection or reporting
None of the above
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16
Is there anything else you’d like us to know about your background or skills?
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17
Please review and confirm your understanding of the following:
*
This field is required.
This is a service-based program, not an influencer or product-focused opportunity
Participation requires consistent engagement and reporting
Physical materials or merchandise are not guaranteed and are earned through participation
Inactivity may result in removal from the program
I will represent PCOSAA respectfully and responsibly
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18
I understand and agree to the expectations of the Teal Impact Corps program
YES
NO
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19
Do you require any accommodations to participate fully?
YES
NO
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20
What support would help you be successful in this program?
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21
If accepted, how do you hope your involvement in Teal Impact Corps will create impact—for yourself or others?
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22
Consent & Certification
*
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I certify that the information provided is accurate to the best of my knowledge
☐ I understand that acceptance is not guaranteed and placement is based on program capacity and alignment
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23
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24
Date
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Date
Year
Month
Day
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