Step 1 of 5 - Contact Info

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Contact Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth

MM slash DD slash YYYY

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Contact Method(Required)

Phone

Demographics

Race/Ethnicity(Required)

Gender Identity(Required)

Primary Language Spoken(Required)

What Type of Area Do You Reside In?(Required)

Are you a U.S. military veteran?

Includes individuals who have served in any branch of the U.S. Armed Forces, including the National Guard or Reserves, regardless of discharge status.

Yes

Prefer not to say

Do you identify as a person with a disability?

This may include physical, sensory, cognitive, intellectual, developmental, or mental health disabilities, whether visible or invisible.

Yes

Prefer not to say

Lives Experience & Interests

Have you ever participated in community advocacy before?(Required)

Yes

What types of activities are you interested in?(Required)

Sharing your story

Community meetings

Surveys

Focus groups

Volunteering

Outreach

Other

If other, please list activities here:(Required)

If you have lived experience with chronic, rare, or long‑term health conditions and feel comfortable sharing, please tell us anything that helps us understand your perspective as a patient advocate.

Is there anything about your experience navigating the healthcare system for yourself or someone you care for that you would like us to understand as we support your advocacy work?

Story Sharing & Visibility

Would you like to be contacted about opportunities to share your story publicly?

Yes

Maybe

If you’re open to sharing, what types of storytelling opportunities interest you?

If other, list potential opportunities here:

As part of your Patient Advocate membership, you’ll receive a branded NAEHD T‑shirt. Please select your preferred size below.

Consent & Acknowledgement

Membership Dues Acknowledgment(Required)

I understand that Patient Advocate membership dues become non‑refundable after 48 hours. Any intent to cancel must be submitted within 48 hours of registration to membership@naehd.org

Yes

Communication Consent(Required)

I consent to receive communications from NAEHD related to my membership, including advocacy opportunities, events, newsletters, updates, and curated resources from partner organizations.

Yes

Information Use Disclaimer(Required)

My information will only be used to support my participation as a Patient Advocate and to provide relevant membership communications. My information will not be shared outside of NAEHD.

Yes

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Membership Type

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Membership Tier

Payment

Membership Level

Patient Advocate

Total

Credit Card

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