ACP Onboarding Form Information for people who want to serve as an Area Contact Person ABOUT YOUName Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* PhoneLocation for Support Directory*We list our Area Contact Persons in our online Support Directory. This includes a broad geographical location, for example, San Antonio, TX, greater Pittsburgh, or eastern Dallas suburbs. How would you like your location to be listed? Consent*Agreeing to be an Area Contact Person for the NSDA includes having your first and last name, general location (as provided above) along with your email posted on the NSDA website (dysphonia.org) and provided to persons who contact the NSDA for support. In addition, you will also receive Support Leadership emails from the NSDA. You may remove your contact information at any time. I agree to how my contact information with be utilized as outlined above.What voice disorder(s) have you been diagnosed with?*As this is a peer-to-peer support network, we encourage people who have a voice disorder like spasmodic dysphonia to participate. Check as many as apply. Spasmodic Dysphonia | Adductor Spasmodic Dysphonia | Abductor Muscle Tension Dysphonia Vocal Tremor Vocal Cord Paralysis / Paresis Other | Use Comment Field below Not Sure Other Voice Disorder or Additional Comments:Are you comfortable with: Participating in Zoom Calls Being active posting on social media platforms Posting in Facebook Groups Comments:CURRENT ENGAGMENT WITH THE NSDAWe would like to know more about you involvement with the NSDA up until this point. We welcome people who are new to the organization. Which resources that the NSDA provides are you familiar with? NSDA Website (dysphonia.org) NSDA Healthcare Referral List NSDA Support Directory "Our Voice" Newsletter NSDA YouTube Channel Various Awareness Materials Have you ever participated in: NSDA Symposium NSDA Support Group | In-person NSDA Support Group | virtual NSDA Leadership Workshop NSDA Event like Walk for Talk Why would you like to be an Area Contact Person?NSDA Policies Consent*The NSDA has a Conflict of Interest Policy and Code of Ethics Policy. We ask you to download the files below and review these policies. These serve as guidelines when serving as an Area Contact Person for the NSDA, I have reviewed and agree to the NSDA Code of Ethics and Conflict of Interest Policy.CAPTCHA NSDA Conflict of Interest PolicyDownload NSDA Code of Ethics 2020Download
