Name(Required) First Last Email(Required) PhoneAddress City(Required) State(Required) Zip Code What is your connection to mitochondrial disease?(Required) Patient Parent Spouse Caregiver Son Daughter Sibling Grandparent Grandchild Aunt Uncle Cousin Niece Nephew Friend Teacher/Educator Medical Professional Physician Nurse Genetic Counselor Social Worker Researcher Industry Rep Other Which mitochondrial disorder are you most familiar with?(Required) Alpers' Disease ACAD9 Deficiency Autosomal Dominante Optic Atrophy (ADOA) Barth Syndrome CACT Deficiency CPEO Complex I Deficiency Complex II Deficiency Complex III Deficiency Complex IV Deficiency Complex V Deficiency CoQ10 Deficiency CPT I Deficiency CPT II Deficiency Creatine Deficiency Syndrome CUD/Primary Carnitine Deficiency Friedreich's Ataxia GAII/MADD Deficiency Kearns-Sayre Syndrome (KSS) Lactic Acidosis LCHAD Deficiency Leigh Syndrome Leukodystrophy LHON LHON Plus Luft Disease MCAD Deficiency MCKAT Deficiency MELAS MEPAN MERRF MIRAS Mitochondrial Cytophy Mitochondrial DNA Depletion Mitochondrial Encencephalopathy Mitochondrial Myopathy MNGIE M/SCHAD Deficiency Multiple Mitochondrial Dysfunction Syndrome NARP Pearson Syndrome POLG Mutations POLG 2 Primary Mitochondrial Myopathy Pyruvate Carboxylase Deficiency Pyruvate Dehydrogenase Deficiency Pyruvate Dhydrogenase Complex Deficiency (PDCD) SCAD Deficiency Thymidine Kinase 2 Deficiency (TK2) VLCAD Deficiency Undiagnosed Other 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 Select AllIn 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) CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
