PsoFun > Be an Ambassador > Join the program!  

Become a Youth Ambassador

Please fill out the form below and click "submit" when you are finished.
First Name  *
Last Name  *
Address
City  *
State  *
Zip
Phone
Email  *
Parent's name and phone  *
date of birth  *
Date you were first diagnosed with psoriasis/psoriatic arthritis  *
What type of psoriasis do you have?  *
Who is your dermatologist?
What is your dermatologist's phone number?
How are you currently treating your psoriasis?  *
Personal interests/hobbies  *
Why do you want to find a cure?  *
How are you helping to find a cure?  *
Wait - we need your parent to review this!
 *

Visit the National Psoriasis Foundation website at www.psoriasis.org »