The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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Required format:

RVeNHxuU9LJbfiy5fLxSVmQ

KIDS Nebraska Application

Thank you for your interest in KIDS Nebraska. We are a local chapter for iCAN KIDS, an active advisory group of kids, adolescents, and teens focused on understanding, communicating and improving medicine, research and innovation for children.

KIDS Nebraska is open to young people ages 13 – 18 living in Nebraska and western Iowa. If you live in a different region, please check with iCAN (the International Children’s Advisory Network) to see if there is a local chapter closer to home. Members must be willing to commit to at least one year with KIDS Nebraska. Participation in meetings is required. Members also have the opportunity to contribute to international projects and surveys that interest them.

Please help us get to know you better by answering the questions below. After you submit this application, a member of our KIDS Nebraska leadership team will reach out to you.

Today's Date

M-D-Y

Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Home Address (including city and state)

* must provide value

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Phone Number

* must provide value

This phone number is

* must provide value

Your number

Your parent/guardian's number

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Is this a cell phone?

* must provide value

Yes

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Student Email

* must provide value

Parent/Guardian Email

* must provide value

Parent/Guardian Name(s)

* must provide value

Grade in School

* must provide value

7th Grade

8th Grade

9th Grade, Freshman

10th Grade, Sophomore

11th Grade, Junior

12th Grade, Senior

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Name of School

* must provide value

Why do you want to be a member of KIDS Nebraska?

* must provide value

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How did you find out about KIDS Nebraska?

* must provide value

Do you have a condition that requires regular care from a doctor?

* must provide value

Yes

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Are you in a clinical trial right now?

* must provide value

Yes

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Yes

Health Care

* must provide value

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Medicines

* must provide value

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Medical Conditions

* must provide value

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Medical Research

* must provide value

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Health Care Professions

* must provide value

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Do you have access to a phone or computer and the internet at home?

* must provide value

Yes

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Please describe what you do not have access to at home:

* must provide value

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Application Status

In-progress

Active

Inactive

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.