RARE Compassion Program Interest Form

Each year, the RARE Compassion Program program connects healthcare students and individuals / families with rare diseases to help foster meaningful provider-patient relationships, inspire careers in rare disease care and research, and ultimately, through patient-centric listening and interactions, build the next generation of future medical professionals as key advocates for their patients. These connections give our individual / family participants the chance to influence the future of medicine, share their stories, and learn more about the medical system from their student partners. For more information about the program visit globalgenes.org/compassion

First Name

Last Name

Which of the following best describes you?

Medical / graduate student interested in joining the programPatient interested in joining the programCaregiver interested in joining the programConnected with a medical / graduate school / students (e.g. professor, dean, advisor)Connected with advocacy organizationOther

What type of medical / graduate student are you e.g. medical student, nursing student, pharmacy student etc.

What medical / graduate school are you connected with?

What advocacy organization are you connected with?

Please write in your role.

Name of advocacy organization

Name of colleague or fellow student

Name and year of event / conference

Name of medical / graduate school

Name of medical / graduate school club or program

Name of Patient Advocacy Group

Name of professor or mentor

Name of previous participant

Name of friend or family

Please explain:

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