I Want to Help Catie's Cause

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Name* This field is required.

First Name

Last Name

Suffix

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Email* This field is required.adding your email will include you in our email list

example@example.com

Confirm Email

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Cell PhoneIf you provide your cell, you are opting in to future texts (approximately four per year)

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I am a......* This field is required.select all that apply

Concerned Parent

Teacher/Professor for can help educate my students and/or their parents

Medical Doctor (or medical student, medical researcher)

Health Care Professional other than a Doctor

Young Adult (18-25)

Friend of Catie

Mental Health Professional

Other

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In our question "I am a...." you indicated "other", please expand

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Expand here on your Medical/Health Profession Work (optional)If you selected that you are a medical professional, please expand here upon your area/s of expertise, and how you can assist us

You make provide as much information as you would like in this section.

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Ways I can help Catie's Cause (select all that apply)

sharing/posting your content to my social media

distributing materials to those I know (students, parents, patients, friends)

Volunteer in whatever ways I can be helpful

making my peers aware

advocating for change

I'm willing to offer services "in kind" to Catie's Cause

I want to donate to The Cause, we are a 501c3, IRS approved public charity

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What services "in-kind" can you offer?Thank you!!

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As a volunteer where can we count on your help?

Creating content for social media

Fundraising

Contacting others to book a presentation about Catie's Story and the safe use of acetaminophen

Visiting local schools/community groups/colleges, etc... to present Catie's Story and teach others about the safe use of acetaminophen

Other

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You indicated "other" on the question, "where can we count on your help". Please share more here.

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Do you want to receive FREE downloadable infographics? These are for personal use, or for patients/clients/students....

YESNO

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When Catie's Cause has a presentation for Young Adults and/or Health Professionals, may we contact you to help?

YESNO

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I am a .....(use the down arrow, scroll and click to select all that apply)

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I can help by....(use the down arrow, scroll and click to select all that apply)

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Other ways I can help which were not listed on your drop down menu include:

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Were you aware of the dangers of Acetaminophen before you heard Catie's story?

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Were you aware of the dangers of acetaminophen containing medications before hearing Catie's Story?You may select up to three answers

Yes, I was aware it could lead to liver failure, even death.

Yes, I was personally harmed or had a negative experience with acetaminophen.

Yes, I know someone who was harmed or had a negative experience with acetaminophen, aside from Catie.

I was aware there were dangers, but not to the extent that I know now.

I had absolutely no idea there were dangers related to acetaminophen use.

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Have you, or someone you know been impacted by acetaminophen use and can you share the story with us? (Names will be omitted for privacy.)

YESNO

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Please share your story here.

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Address for Periodic Snail Mail (Optional)adding your address will permit us to mail to you periodically, although snail mail is so 1960!

Street Address

Street Address Line 2

City

State

Zip Code

Country

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If you wish to share anything further with us, feel free to use this free text box below to do so.

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When you hit submit you are accepting the following.

I agree to sign electronically using my mouse, my finger, or whatever method is available to me on the device on which I sign. Should I not be able to sign electronically, typing my name in the name box/es of this form will also constitute an electronic signature. A fully executed copy of this form will be provided to me at the email address I provide within this form. If I prefer to sign this document manually, I will contact karen@catiescause.org and arrange for a date and time to complete this form manually.

I am also agreeing to be added to the email list of Catie's Cause and understand I will receive newsletters, notifications, donation requests etc... in the form of electronic communications I can unsubscribe at any time.

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Signature

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Disclaimer: None of the information contained within or provided by Catie's Cause is intended to serve as medical advice of any kind. Always consult your own doctor and pharmacist about the use or discontinuation of use of any and all medication whether prescription or over the counter. Some data may be outdated but we endeavor to post the most relevant and current information possible. Our goal is to bring more awareness and education around acetaminophen use and dangers.