Project Plasma Registration Form
Please complete this form to register your Project Plasma campaign
First Name
Last Name
Email
College / University Type
Four-Year College
Community College
College / University:
Community College
Please indicate which describes you best:
Student
School Administrator
Faculty
Student
Current Year
Freshman
Sophomore
Junior
Senior
Post-Grad
Graduation Year:
Please estimate a date when you would like to start this campaign?
Please estimate a date when you would like to end this campaign?
Do you have any specific goals you would like to accomplish at the end of your campaign?
Faculty/Administrator
Which office or department do you work in?
What is your title?
Do you interact with students looking for community service or volunteer opportunities?
Yes
No
Have you donated plasma before?
Yes
No
Please describe your experience:
Have you had personal experience with GBS, CIDP, or any of the other conditions we advocate for?
Yes
No
Condition Information
What is your relationship to the condition?
Patient
Caregiver
Family or Friend
Medical Professional
Condition of Interest
Year Diagnosed
How did you hear about us?
Please select...
College department
College Administrator
Professor
GBS-CIDP Foundation Website
Email
Social Media
Internet Advertisement
Other
Would you like to receive more information about the foundation and receive the Foundation e-newsletter?
Yes
No
Contact Information