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Join the debra Impact Network!

Our debra Impact Network Members have a wide range of talents but all share a commitment to eradicating EB and servicing the EB Community.

Fill out the form below to register your interest. A staff member will reach out after you complete the form.

Apply to Join

First Name*

Last Name*

Email Address*

Preferred Phone*

Address, line 1

City

State

Zip Code

Birthdate

Connection to EB*

Person with EB Parent of Person with EB Spouse of Person with EB Sibling of Person with EB Child of Person with EB Grandparent of Person with EB Other (please specify)

If other connection, please explain here:

In what ways are you already involved with debra of America? (select all that apply)

Receive debra emails and follow social media pages

Yes No

Attend debra of America events

Yes No

Organize events

Yes No

Utilize debra's direct services and educational materials

Yes No

Fundraise

Yes No

Other Ways (please specify)

Please check all of the areas you are interested in for the purposes of the debra Impact Network:

Advocacy

Yes No

Clinical Research and Surveys

Yes No

Events

Yes No

Digital and Print Media

Yes No

Social Media

Yes No

Mentoring

Yes No

Office Support/Administrative Tasks

Yes No

Programs and Initiatives for the EB Community

Yes No

Other Interest (specify)

How much time would you like to spend volunteering?

What is the best way to communicate with you?*

If you would like, please share your blog or social media handles:

Blog Site URL

Facebook Profile

Instagram Username

Twitter Handle

Other Blog/Social Media

By submitting this form, I am allowing debra of America to save the information on this form and contact me if debra of America sees potential opportunities for me to participate in various projects, committees, and outreach activities. debra of America may also contact me from time to time to see if I'd like to participate in projects with external organizations that are seeking community perspectives, such as surveys for clinical practical guidelines and documentaries.

Submit

Address Line 1 | City, State | Contact Email | Cell Phone

Facebook

Twitter

Instagram

Completed.

Thank you for registering. Your submission is being reviewed by debra staff.

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