PCOS Advocacy Day 2018 - Local Advocate Registration Form
Overview - Supporting as a Local Advocate
If you are unable to attend PCOS Advocacy Day in Washington, DC on May 17th (pcos.ch/advocacy), but would like to support our efforts by meeting with your Congressperson at their home district office near you, please register using the form below. We will provide you with training and advocacy materials for your meeting.

IMPORTANT SCHEDULING NOTE:
We will attempt to schedule a meeting with your Congressperson's office during the week of May 14th based on your local office's availability.

DONATIONS:
Coordinating Advocacy Day and local meetings takes significant resources. Please consider making a donation to support our efforts at pcoschallenge.org/giving/

PRIVACY STATEMENT:
PCOS Challenge respects your privacy and is committed to keeping your personal information confidential.

Please Complete the Form Below to Register
First Name *
Your answer
Last Name *
Your answer
Email Address *
Your answer
Mobile Phone *
In case we need to contact you regarding your meeting.
Your answer
Organization/Company
If Applicable
Your answer
VOTING ADDRESS
Please list the address where you are registered to vote.
Address *
Your answer
Suite/Apartment/Unit
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Meeting Availability
Which days can you be available all day (8:00am-5:00pm) to go to your Representative's home district office? Check all that apply. *
Required
I understand that I am responsible for arranging my own transportation to and from my Representative's home district office. *
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