PAO Legislative Champions Form
Please enter information to sign up to help fight for our patients
Name
Title
Home Address
City
Zip Code
Home Phone
Cell Phone
Email
What is the best way to contact you? (Check all that apply)
Do you have a relationship with any Pennsylvania State Senator or State Representative?
Clear selection
If yes, please describe
Are you willing to contact your Pennsylvania State Senator or State Representative as needed?
Clear selection
Are you willing to attend fundraisers on behalf of the PAO?
Clear selection
Would you be willing to attend in person meetings with your Pennsylvania State Representative or State Senator?
Clear selection
Would you be interested in a PAO legislative App for your smartphone?
Clear selection
Are you on Social Media? (check all that apply)
Would you participate in an at Home Advocacy Day if it was held after Labor Day?
Clear selection
What can we do to get you involved in advocacy?
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