Amazon Lifeline Email List Application Form

	Amazon Lifeline Email List Application Form
	Required items are in bold. Items in regular text are optional.

First name or nickname:
State, country or region:
Email:
Chronic illness/disability:
How long since onset:
Are you able to work:	Full-time Part-time Sporadically Not at all
Gender:	Female Male Mixed or in transition
Birthday: (mm/dd/yyyy)	/ /
Sexual preference:	Lesbian Bisexual Gay Queer Heterosexual Other
Partnership status:	Single Partnered Civil Union Married Celibate Undecided
Want a penpal?	Yes No
Are you the partner, friend or caregiver for someone with a chronic illness?	Yes No
Why do you want to join our email list? (You may also use this space for other comments.)

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Page last revised: 02/10/2004