HPNA Raffle Entry

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HPNA Raffle Entry

First Name *

Last Name *

Email *

Enter email address and verify before moving to next entry.

Mobile *

Enter mobile number, including area code, like: 123-456-7890.

State *

Enter your two-letter State/US Territory abbreviation.

Zip Code *

Type your five-digit zip code.

Role *

Please enter your current professional role

Credentials *

Enter credentials (such as RN, BSN, PhD)

Statements

Select all statements that apply to you.

I have worked with patients who accessed MAID.

I have been asked about MAID by a patient.

Until this conferences, I was unaware of MAID in the US.

Other:

Knowledge

I consider my knowledge level of MAID to be:

Beginner

Intermediate

Advanced

Clear selection

Interests

Check all that apply:

Advocacy

Clinical Education

Volunteering

Organization

Choose the organization(s) you wish to be in contact with.

Arizona

California

Colorado

Florida

Georgia

Hawai'i

Maine

New hampshire

New Jersey

New Mexico

New York

North Carolina

Ohio

Oregon

Vermont

Washington

Academy

C & C

Completed Life

Death with Dignity

ACKNOWLEDGEMENT *

I acknowledge that my information will be provided to the organization(s) I have selected above, and that a representative of the Aid in Dying Collaborative may contact me should I win this raffle.

Yes

Required

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Forms

This form was created inside of Maine Death with Dignity.