Polk County In-Person Lupus Support Registration

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Thank you for your interest in our Kansas City Lupus Support Group! Please complete this form to notify our facilitators, Beverly Tinsley-Minniefield and Jasmine Lewis, and share some information about yourself.

First and Last Name *

Email Address *

Phone Number

City *

State *

What is your lupus connection? *

I might have lupus.

I am newly diagnosed with lupus (within 2 years).

I have lupus.

I am a lupus caregiver/care partner for a family member.

I am supporting a friend with lupus.

I am a medical provider.

I lost a loved one due to lupus.

Other

If you have lupus, what type of lupus were you diagnosed with?

Systemic Lupus (SLE)

Discoid “Skin” Lupus (DLE)

Lupus Nephritis (LN)

Central Nervous System Lupus (CNS)

I have not been diagnosed with lupus.

I am not sure.

N/A

Please share any topic(s) you'd like this group to discuss.

Submit

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