Bronchiectasis and NTM Volunteer Interest Form
The Bronchiectasis and NTM Association offers various opportunities for you to share your story, promote awareness, support research, and join the effort. Please fill out this survey to be contacted when opportunities become available.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I would like to be notified about opportunities to share my story.
*
Yes
No
Maybe
I am interested in participating in the following activities
*
Podcast Episodes
Short Video Reels
Video Opportunities
Panel Discussion
Patient Interview
Volunteering
Other:
Special skills or background
Fluent in a language other than English
Fluent in sign language
Experienced in public speaking
Experienced in research
Born outside of the United States
Multiple family members have bronchiectasis
Currently or formerly a healthcare professional (e.g., MD, RN, RT, CNA, PA, etc.) Please explain
Other:
Which lung condition(s) have you been diagnosed with? (Select all that apply.)
Bronchiectasis
Nontuberculous mycobacterial (NTM) lung disease
COPD
Prefer not to answer
With which group(s) do you most identify? (Select all that apply.)
Person living with COPD, bronchiectasis, and/or NTM lung disease
Respiratory therapist
Caregiver
Family member or friend
Medical provider
Other:
Please explain:
*
Submit
Should be Empty: