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Registration
* Required Information
* Information visible to users searching our site
A. Registration Info
1) Username
2) Password
3) Organization Name
4) Org Admin Name
5) Org Admin Phone
6) Org Admin Email
B. Contact Information
1) Address
2) City
3) State
4) Zip Code
5) Phone Number (XXX-XXX-XXXX)
6) Fax Number (XXX-XXX-XXXX)
7) Email Address
 
8) Contact Names & Email addresses:
8a) Executive Director
Name
Email
8b) Director of Fundraising  
Name
Email
8c) Clinical Trial Recruitment Coordinator  
Name
Email
 
9) Website address
10) Support Group logo
11) Mission/Description
C. Identification Information
1) Medical Condition
*Please limit selection to 5 conditions
2) Keywords
D. Membership
1) If you are a member of any association consortiums for research or fundraising please list them here
2) Population Served
(Check all that apply)

Women

Men

Children

Teens

Patients

Caregivers
3) Organization Area

4) Number of Chapters
5) Chapter locations
6) Year Founded
7) Number of Active Members
8) Description of advocacy activities
9) Web page profile
10) Approximately how many hits does your website receive in a week?
Don't track
E. Communication
1) How do you communicate with your members?

Mail

Email

Telephone

2) Approximately what percentage is on email? %
3) If you have a direct mail list, how many mailing addresses does it contain?
4) If you have an email list, how many email addresses does it contain?
F. Fundraising
1) List all types of email communications software your organization uses
2) List all types of Fundraising software that your organization uses
3) What is your annual fundraising budget?
 $
4) List the names (if any) of Pharma or Other Industry Sponsors associated with your organization
5) Donation Url
G. Clinical Trial Participation
1) List ongoing relationships (if any) with clinical trials sponsors or academic research centers?
2) Do you currently give members information regarding clinical trials?
2a) If No, are you interested in doing so?
3) How many clinical trials has your organization actively informed your membership about in the past 12 months?
4) How many people could you reach to communicate a trial opportunity?
Patients
Friends/Family
5) How do you inform members about clinical trial opportunities?

Mail

Email

Telephone
6) What do you require of sponsors who wish to publicize trials?

7) What is your usual enrollment response rate for clinical trial opportunities?
% Don't track
If you are currently publicizing a clinical trial, Add Clinical Trial Information