AACT Young Adult Connect Form

Connect with other Young Adult Mitochondrial Disease Patients

This contact form is generally used to connect with other  Young Adult Mitochondrial Disease Patients through the Adult Advisory Council Team (AACT).  All other inquires will be forwarded to the appropriate staff member(s).

Please note: we are a lay organization; therefore we cannot give medical advice. For medical advice, please contact your physician(s) and/or request a doc list.

 

If you are contacting us to connect with a Volunteer UMDF Support Ambassador:
please tell us if you are comfortable with us giving out your email address and/or phone number to UMDF Support Volunteer(s). Please tell us who is affected or suspected of having Mitochondrial Disease (yourself, your child(ren), your spouse, etc.).
 

If you are contacting us to request a list of doctors:
please tell us who the list is for (yourself, your child, your friend, etc.) and his/her age, and the city/state in which he/she is living in. If there are multiple people who are, or may be, affected, please list each person.
 

If you are contacting us to request materials:
please confirm the address in which we should send materials to, tell us what materials you would like or ask for a list of materials if you are unsure as to what is currently available, and let us know approximately how many people you are planning on providing information to.

First Name

Last Name

Email

Address One

Address Two

Company

City

State

Zip

Phone

I want to Connect with Affected Young Adults Yes

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