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Home / Get Involved / NBCA Interest Questionnaire

NBCA Interest Questionnaire

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Email
How did you hear about NBCA?
What precipitated your interest in blood clots or clotting disorders?
Approximately how much time are you able to commit on a monthly basis?
How do you wish to get involved with NBCA?
- Stop The Clot Walk
- Golf Tournament
- Personal Fundraising Appeal
- Other?
Do you have access to local resources or special funding opportunities?
- Yes
- No
If you answered "yes" above, please explain.
Do you have access to key medical leaders or institutions involved with blood clots or blood clotting disorders?
- Yes
- No
If you answered "yes" above, please provide details or contact names.
Do you have access to a pre-existing base of volunteer support?
- Yes
- No

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Phone: 703.935.8845
Toll Free: 877.4.NO CLOT
Hours: Mon-Fri, 8:30am - 5:00pm EDT

National Blood Clot Alliance
8321 Old Courthouse Road
Suite 255
Vienna, VA 22182

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Disclaimer

NBCA provides the information and materials on this site for general information purposes only. You should not rely on the information provided as a substitute for actual professional medical advice, care, or treatment. This site is not designed to and does not provide medical advice, professional diagnosis, opinion, treatment, or services to you or any individual. If you believe you have a medical emergency, call 911 immediately.