JA Power Pack Request Form

The JA Power Pack is intended for Children/Teens with arthritis only and is limited to one per child. Please note – you will not be able to save any information you submit nor have the ability to return and complete your application.

*Pack Quantity (maximum of 2)

*Parent 1 First Name

*Parent 1 Last Name

*Shipping Address

*City

*State

*Zip Code

*Mobile Phone

Home Phone

*Email

Parent 2 First Name

Parent 2 Last Name

Home Address (if different than above)

City

US States

Zip Code

Mobile Phone

Home Phone

Permission for The Arthritis Foundation to share your name with other organizations/sponsors?

How did you hear about the JA Power Pack?

Once your JA Power Pack form is submitted, you will receive a confirmation email. If you do not receive a confirmation email within 24 hours of submitting your form, contact [email protected]