MitoChampions Areas of Interest

Name(Required)

First Last

Email(Required)

Phone

Address

City(Required)

State(Required)

Zip Code

What is your connection to mitochondrial disease?(Required)

Which mitochondrial disorder are you most familiar with?(Required)

How would you like to engage as a MitoChampion? (Check all that apply)(Required)

One-on-One Support/Mentorship

Awareness (i.e. school, community, general, etc.)

Fundraising

Legislative Advocacy

Education

Focus Group (give feedback to MitoAction so they can better engage with the community)

Other

In what other ways would you like to engage as a MitoChampion?(Required)

What is your preferred method of communication? (Check all that apply)(Required)

Phone

Text Message

E-mail

Facebook

How often would you be available to meet virtually?(Required)

Bi-monthly

Monthly

Are there any special projects that you are particularly interested in? (Please briefly describe)

What do you hope to get out of volunteering as a MitoChampion?(Required)

CAPTCHA

This field is for validation purposes and should be left unchanged.

Monthly Expert Series