2017 Dental Access Now! Advocacy Day Registration
Please register below for Dental Access Now!'s Advocacy Day on Tuesday, March 21, 2017.
First Name *
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Last Name *
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Organization (if applicable)
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Email address *
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Phone number (preference for cell phone so we can reach you on the day of the event) *
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Home address *
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City *
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Zip Code (Preference for 9 digit zip code. If you don't know yours, find it here https://www.usps.com/zip4/ ) *
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If you already know who your State Representative is, please list them below.
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If you already know who your State Senator is, please list them below.
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What is your previous experience with legislative visits? *
Would you be interested in volunteering as a "Legislative Visit Leader" for one or more meetings with legislators? (Expectations would include: Participating in a "Leader" conference call prior to Advocacy day, leading a meeting with a legislator, gathering and turning in evaluation forms, etc.) *
Please rate your knowledge level of the Dental Access Now! project. * *
Are you available all day on Tuesday, March 21? *
Please specify your meal preference *
Please list any special accommodations you require.
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How did you hear about advocacy day? Please be specific.
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Other questions/comments?
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