First Connection Request Form

Patti Robinson Kaufmann First Connection Program
Online Request Form

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip/Postal Code *

Please note, requests can only be accommodated for individuals who live in the US or Canada.

Email Address

Phone Number *

Date of Birth * +

With which race(s) do you identify? (Select all that apply) *

Do you identify as Hispanic, Latino or Spanish origin? *

Yes

No

Prefer not to answer

Please specify your gender. *

Female

Male

Another gender

Prefer not to answer

Primary language? *

Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? *

Yes

No

Prefer not to answer

Disease of Interest *

Leukemia Disease Type

Other Disease Type

Myeloproliferative Neoplasms Disease Type

Lymphoma Disease Type

NHL Subtype

I am a *

Date of Diagnosis

The best time to reach me is

Comments

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The Leukemia & Lymphoma Society (LLS) is the world's largest voluntary health organization dedicated to funding blood cancer research, education, and patient services. LLS's mission: Cure leukemia, lymphoma, Hodgkin's disease and myeloma, and improve the quality of life of patients and their families.

Need Help? Contact us

infocenter@lls.org

(800) 955-4572

For general information about LLS First Connection program and other support resources, please visit: https://www.lls.org/support-resources/peer-peer-support or https://www.lls.org/support-resources

Patti Robinson Kaufmann First Connection ProgramOnline Request Form

Patti Robinson Kaufmann First Connection Program
Online Request Form