Asthma Summit 2019
May 7-8
Sacramento, CA
REGISTRATION
Please complete this registration form to confirm your attendance for the Asthma Summit.
First name *
Your answer
Last name *
Your answer
Job title *
Your answer
Organization *
Your answer
Organizational address *
Your answer
Phone *
Your answer
Email *
Your answer
Is it OK to share your contact information on the meeting's participant list? *
Please provide 1-3 sentences describing your organization to share with other participants. *
Your answer
Do you plan to attend Day 1 (May 7th)? *
Do you plan to attend Day 2 (May 8th)? *
If you plan to attend Day 2 (May 8th), are you able and willing to meet with policymakers to provide education on the value of asthma home visiting services? (Providing education about the value of services is NOT considered lobbying.)
If you plan to attend Day 2 (May 8th), are you able and willing to meet with policymakers in support of specific legislation to provide reimbursement for asthma home visiting services? (This activity is considered lobbying.)
Lunch will be provided. Please indicate any dietary restrictions you have:
Your answer
Do you require a travel stipend in order to attend the conference? *
If YES, please estimate travel funds needed:
Your answer
If you plan to attend BOTH days, we may have funds to support a night in a hotel. Will you require a hotel stipend for the night of May 7th in order to attend Day 2 on May 8th?
Please list any questions you have here for the meeting organizers.
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