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Support and Action Group/Volunteer Signup Form

The Charcot-Marie-Tooth Association is working hard to provide the services of a support and action group to everyone. To do this, we need to know if people are interested in attending or starting support and action groups in their area.

You can use this form to tell us if you would attend a support and action group if there were one in your area. We'll keep your information on file and notify you if a support and action group begins meeting in your area. You can also tell us if you are willing to start a support and action group or are willing to help someone else start a group.

Please also tell if you would be interested in doing volunteer work for the CMTA (mailing letters, making phone calls, helping plan or set up local events, etc.) or if you would be willing to be interviewed by the media if we have an opportunity to do a story in your area.

Required fields are marked with an asterisk().

Title:

First Name:

Middle Initial:

Last Name:

Address:

Address2:

City:

State:

Zip Code:

Daytime Phone:

Evening Phone:

Email:

Please tell us about your interest in a support and action group by checking one of the following options:

	I am interested in attending a support and action group.
	I am interested in starting and facilitating a support and action group.
	I am interested in being a co-facilitator of a support and action group.
	I don't want to facilitate or co-facilitate, but I will help run a support and action group.
	I am not interested in attending a support and action group.

If you have any additional questions or comments about participating in a support and action group, please use the box below to tell us about them.

If you had the opportunity to do volunteer work for the CMTA, approximately how many hours per month would you be willing to work?

	16 or more hours
	11-15 hours
	6-10 hours
	1-5 hours
	Not able to volunteer

What type(s) of work would you be willing to do? Please check all that apply.

	Help with mailing letters/brochures
	Make/answer phone calls
	Help with fundraising and other events
	Staff booths at conferences/symposia
	Other (please explain):

If the media in your area were interested in doing a story on CMT, would you be willing to be interviewed for any of the following? Please check all that apply.

	Television show/spot
	Radio show/spot
	Newspaper article
	Magazine article
	Public appearance
	No interviews, please

Please use the box below to tell us a little about yourself, including any interesting accomplishments, useful skills or abilities, or access to facilities or resources that will help us match you up with volunteer opportunities.

Charcot-Marie-Tooth Association 2700 Chestnut Street, Chester, PA 19013
Toll-Free (US Only): 1-800-606-2682 Phone: 1-610-499-9264 Fax: 1-610-499-9267
info@charcot-marie-tooth.org
© 2006 - 2010 Charcot-Marie-Tooth Association. All Rights Reserved.