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Lichen Sclerosus Support Network Sponsored Membership Application
Application for sponsored membership
* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Country
*
Your answer
Do you have a vulva?
*
Yes
No
Have you had a medical professional confirm an LS diagnosis? (choose one)
*
Yes
No
What are your primary concerns regarding lichen sclerosus? (choose all that apply)
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Getting diagnosed
Treating symptoms and flares
Sexual health and wellness
Mental health
Diet and nutrition
Required
Currently, how are you doing mentally and physically with your LS? (3-5 sentences)
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Your answer
What do you want to get out of the community? (2-3 sentences)
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Your answer
Please tell us in 2-3 sentences why you’d like to be considered for a sponsored membership to the LS Warriors community through the Lichen Sclerosus Support Network.
*
Your answer
I understand that by completing this form I will be added to LSSN's email list. I understand that should I unsubscribe I will not be able to receive communication about my membership and will be removed from the program.
*
I understand
Required
Send me a copy of my responses.
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