PAO Legislative Champions Form

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Please enter information to sign up to help fight for our patients

Name

Title

Home Address

City

Zip Code

Home Phone

Cell Phone

What is the best way to contact you? (Check all that apply)

Phone Call

Text Message

Do you have a relationship with any Pennsylvania State Senator or State Representative?

Yes

Clear selection

If yes, please describe

Are you willing to contact your Pennsylvania State Senator or State Representative as needed?

Yes

Clear selection

Are you willing to attend fundraisers on behalf of the PAO?

Yes

Clear selection

Would you be willing to attend in person meetings with your Pennsylvania State Representative or State Senator?

Yes

Clear selection

Would you be interested in a PAO legislative App for your smartphone?

Yes

Clear selection

Are you on Social Media? (check all that apply)

Facebook

Instagram

Twitter

Would you participate in an at Home Advocacy Day if it was held after Labor Day?

Yes

Clear selection

What can we do to get you involved in advocacy?

Submit

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