AIU Mailing List

AIU Mailing List

First/Last name, Email and State are required. All other information is optional.
AIU will be using MailChimp for our mailing list. Right now as we migrate over we are still using this form. However to make sure the integration is working there are some areas where you will see the message

Do not fill out

This is due to duplicate information.

By giving AIU your name and email you are consenting to receive emails from Adrenal Insufficiency United Board Members and Director. Your contact information will not be shared with any other business or entity without your expressed permission.

We encourage you to fill out as much information as possible as it helps AIU as we seek out partners, grants, and research opportunities.

If you live outside the USA you can still sign up for our mailing list. The phone number input will not work, but it's not required so just skip that.
Full Name (first/last)*
Name (do not fill out this field) Testing New Form

First NameLast Name
Primary Email*

Confirmation Emailexample@example.com
Additional emails separated with a comma
Phone Number (Cell)
Please enter a valid phone number.
May we send text messages to this phone

YesNo
Alternate Number: home or cell
Please enter a valid phone number.
May we send text messages to this phone

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you?*

An adult age 18 or older with Adrenal InsufficiencyThe parent/caregiver of a child under the age of 18 who has adrenal insufficiencyThe parent of an adult 18 or older who has adrenal insufficiencyThe parent/caregiver of an affected adult over 18 who is unable to care for themselvesAn unaffected friend or family memberA health care providerBoth a parent/guardian with adrenal insufficiency and an affected adult with adrenal insufficiencyOther
Birthdate of affected ADULT over 18 (only fill this out if you are the affected adult or the parent/caregiver of an affected adult unable to fill out this form)

MonthDayYear
Date
Birthdate of affected CHILD under 18 (only fill this out if you are the parent/caregiver of the affected child)

MonthDayYear
Date
Birthdates of any other affected children in your household. Please separate each birthday with a comma. 1/12/2021, 4/4/2012 etc.
Donate to AIU: Anything helps

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