SoCal Days of Action
Fill in this form if you plan to attend the 12/9-11 D4CC Action in San Ysidro. You do not need to be a medical professional to attend! We need all allies and activists for this action.
Email address *
Name (as it appears on your official ID)
Your answer
Name you would like to be called
Your answer
I plan to attend (check as many as you will attend): *we need the most people on 12/10
I am interested in:
Profession/Degree (MD, DO, RN, NP, PA, etc):
Your answer
Medical licenses (list current state licenses):
Your answer
Phone number (required if you plan to participate in direct action):
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy