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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:

*2. I live in or near:
(Select one of the available choices or enter a different value.)



3. Please enter your contact information.

*

Name:

 

 

 

 

       

*

 

 

 

City/State/ZIP:

 

    

 

 

 

 

 

 

 

 

 

What's this?

*4.
Question - Required - What is your lupus connection?

5. How did you hear about the Alliance for Lupus Research?
(Select one of the available choices or enter a different value.)



6.

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

   Please leave this field empty

     

 

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