Thank you for your interest in our mentoring program. We are happy to match you with one of our experienced mentors. Once we receive your form, a member of our team will follow up with you. If you have any questions, please email us at peermentors@pkdcure.org.

First Name

Last Name

Address

City

State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip

Email

DOB Please type your birthdate into the field using the format yyyy/mm/dd

Mobile Phone number Use format xxxxxxxxxx

Can we text you? Yes No

What is your relationship to PKD? I have ADPKDI have ARPKDI have a child with ADPKDI have a child with ARPKDI have a family member with PKDI have lost a child to PKDI have lost someone to PKDI work in the PKD field (research/medical)I care for someone with PKDMy friend has PKDSpontaneous mutationPrefer not to answer

When were you / family member diagnosed with PKD?

I would like to share my experiences with the following: Living with PKDLiver CystsLiving donor kidney transplantDeceased donor kidney transplantPeritoneal Dialysis (PD)HemodialysisChronic PainLosing a family member to PKDChildren with PKDParticipation in Clinical TrialsAneurysmNephrectomySpontaneous mutationPre-implantation genetic diagnosis

Please provide general availability. Afternoon Evening Morning Weekdays Weekends Weekly Hold control and click to choose more than one response option.

Any additional information you would like to share?

Comments