Advocacy Visit Form

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Advocacy Visit Form

DATE OF MEETING *

LOCATION OF MEETING *

LOCAL OR ALBANY OFFICE

I MET WITH MY *

STATE ASSEMBLY MEMBER OR STAFFER

STATE SENATOR OR STAFFER

Required

THE FOLLOWING LEGISLATORS WERE PRESENT AT THE MEETING(S) *

ASSEMBLY MEMBER

SENATOR

NEITHER/ NONE

Required

MY ASSEMBLY MEMBER IS *

MY SENATOR IS *

OTHERS WHO ADVOCATED WITH ME

ENTER NAMES AND PROFESSIONAL TITLE/ STUDENT

THE REQUESTS THAT I ASKED OF MY LEGISLATORS WERE: *

SCOPE OF PRACTICE TO INCLUDE DIAGNOSE

NO PERMANENT EXEMPTION

TO SHARE MY REQUESTS WITH THE HIGHER EDUCATION COMMITTEE CHAIRS

Required

I LEFT MATERIALS WITH

ASSEMBLY MEMBER/ STAFFER

SENATOR/ STAFFER

I AM FOLLOWING UP WITH MY LEGISLATORS: *

LIST DATE AND METHOD FOR FOLLOWING UP

I FELT PREPARED FOR THE MEETING *

YES

Required

Please share anything else you think we need to know

NAME *

HOME ADDRESS *

EMAIL *

Submit

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