Alliance for Lupus Research: Survey - Interest Survey - New Walk

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Walk Day Information

Raleigh Durham Walks with Us 2008!

Goal:: $45,000.00
Achieved:: $38,101.60

85 percent of goal achieved.

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Interest Survey - New Walk

Thank you for your interest in the Walk with Us to Cure Lupus Walkathon. Please complete the following survey so we can contact you about your involvement in our program. If you have any questions, you may email walks@lupusresearch.org,
or call our Toll-Free Walk Hotline at
866-WALKALR.

1.

Question - Not Required - I would like more information about:

	Starting an ALR Walk
	Spreading the word about lupus and the work of the ALR
	Participating in an existing ALR Walk

*2.

I live in or near:

(Select one of the available choices or enter a different value.)
Question - Required -I live in or near: Click this to indicate that you will select an existing value. Tab to next input." I live in or near:
I live in or near: Click this to indicate that you will enter a new value. Tab to next input." I live in or near: Provide your answer here

3.

Please enter your contact information.

*

Name:

Title	First Required	Middle Required	Last Required

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Country:

Phone Number:

Employer:

Occupation:

Gender:

Yes, I would like to receive e-mail from Alliance for Lupus Research

Email Format:

Yes, I would like to receive postal mail from Alliance for Lupus Research

Remember me. What's this?

*4.

Question - Required - What is your lupus connection?

	I have lupus
	A family member has lupus
	A friend's family is touched by lupus
	A co-worker's family is touched by lupus
	I work professionally with those touched by lupus
	I have no lupus connection

5.

How did you hear about the Alliance for Lupus Research?

(Select one of the available choices or enter a different value.)
Question - Not Required -How did you hear about the Alliance for Lupus Research? Click this to indicate that you will select an existing value. Tab to next input." How did you hear about the Alliance for Lupus Research?
How did you hear about the Alliance for Lupus Research? Click this to indicate that you will enter a new value. Tab to next input." How did you hear about the Alliance for Lupus Research? Provide your answer here

6.

Question - Not Required - Additional Comments

(Maximum response 255 chars, approx. 5 rows of text)

Spam Control Text: Please leave this field empty

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