Sponsorship Information

NEW Sponsors:
Please complete the following form to join the American Porphyria Foundation. After you complete this form, please follow the instructions on the next page to send your Sponsorship fee to the APF. Annual Sponsorship is $35 for Sponsors who live in the US, $45 for Sponsors outside the US.

Thank you!

* Required

Prefix:
First Name*	Last Name*
Address*
City*	State*	ZIP*
Country*
Phone Number*	Birthdate
E-mail Address

Which of the following best describes you?

Healthcare professional

Patient with porphyria

Family Sponsor

Other interested party

Your answers to the following questions will provide very important information and will have a direct impact on foundation activities.

1. If you are being treated for porphyria, which type do you have:

ALAD Porphyria (ADP)

Acute Intermittent Porphyria (AIP)

Congenital Erythropoietic Porphyria (CEP) (Gunther's disease)

Porphyria Cutanea Tarda (PCT)

Hepatoerythropoietic Porphyria (HEP)

Hereditary Coproporphyria (HCP)

Variegate Porphyria (VP)

Erythropoietic Protoporphyria (EPP) (Protoporphyria)

I don't know/I have not been diagnosed

2. Would you be willing to volunteer for porphyria medical research?

YES

3. Would you like to receive additional educational material regarding porphyria?

YES

The foundation is able to add healthcare professional contact information. For educational and clinical research purposes, the foundation would like to have contact information for the physician who has primary responsibility for managing your porphyria.

The APF will send a comprehensive infomation package on the diagnosis and treatment of the porphyrias to your physician if you are a Sponsor of the APF.

Please complete the requested information below.

Doctor's First Name	Last Name
Doctor’s Organization/Practice Name
Doctor's Street Address
Doctor's City	Doctor's State	Doctor's Zip
Doctor's Phone Number
Doctor's E-mail Address

4. Would you like to receive educational information from the makers of Panhematin (hemin for injection)?* Panhematin is the only FDA approved medication to manage acute porphyrias.

YES

5. What information would you like to see included on the American Porphyria Foundation website that is not already there?

6. In which format would you like to receive the American Porphyria Foundation Newsletter?

via E-mail (electronically)

via regular mail (paper)

7. Would you like to be a Sponsor of the In Touch network so that you can be in contact with others with your type of porphyria?

YES (If yes, please complete an In Touch consent form and return it to the foundation. Download here)

8. Are you interested in hosting an In Touch meeting in your area with the help of the APF?

YES (If not previously completed, please complete an In Touch consent form and return it to the foundation. Download here)

Please type the word "foundation" into the
text field below before submitting this form:

Privacy reminder:
The American Porphyria Foundation is committed to maintaining the privacy of your information.

We will only collect information about you if you voluntarily provide it to us. We will use this information to better understand our Sponsors, and this data will only be shared with our advisors and APF sponsors. Your information, including your email address, will never be sold to any other 3rd party organization under any circumstances without your consent unless required by law. You may remove yourself from this list at anytime by contacting the APF.

*Ovation Pharmaceuticals has provided an unrestricted educational grant to the APF for the support of our website and educational materials. By answering YES to this question, I permit Ovation to use the contact information I have provided to contact me with information and educational materials about porphyria and FDA approved treatments for porphyria.

The APF is not responsible for the interpretive translations in other languages.

The information contained on the American Porphyria Foundation (APF) Web site or in the APF newsletter is provided for your general information only.

The APF does not give medical advice or engage in the practice of medicine. The APF under no circumstances recommends particular treatments for specific individuals, and in all cases recommends that you consult your physician or local treatment center before pursuing any course of treatment.

All information and content on this Web site are protected by copyright. All rights are reserved. Users are prohibited from modifying, copying, distributing, transmitting, displaying, publishing, selling, licensing, creating derivative works, or using any information available on or through the site for commercial or public purposes.

The American Porphyria Foundation (APF) Tax Forms 990 are readily available to the public. If you would like a copy, please contact the APF: 4900 Woodway, Suite 780, Houston, TX 77056. Toll free: 1.866.APF.3635.