Survey - 2020 LUNG FORCE Capitol Hill Advocacy Week

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2020 LUNG FORCE Capitol Hill Advocacy Week

Registration Form

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Question - Required - First Name*:

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Question - Required - Last Name*:

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Question - Required - Email Address*:

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Question - Required - Address (Line 1)*:

Question - Not Required - Apartment:

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Question - Required - City*:

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Question - Required - State*:

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Question - Required - Zip (+4)*:

Question - Not Required - Address where participant is registered to vote:

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Daytime Phone*:

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Question - Required - Cell Phone*:

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Position*:

(Select one of the available choices or enter a different value.)
Question - Required -Position*: Click this to indicate that you will select an existing value. Tab to next input." Position*:
Position*: Click this to indicate that you will enter a new value. Tab to next input." Position*: Provide your answer here

If you are a LUNG FORCE Hero, please provide additional info?

(Select one of the available choices or enter a different value.)
Question - Not Required -If you are a LUNG FORCE Hero, please provide additional info? Click this to indicate that you will select an existing value. Tab to next input." If you are a LUNG FORCE Hero, please provide additional info?
If you are a LUNG FORCE Hero, please provide additional info? Click this to indicate that you will enter a new value. Tab to next input." If you are a LUNG FORCE Hero, please provide additional info? Provide your answer here

Question - Not Required - If you are a LUNG FORCE Hero, will you be coming with a caregiver? Caregiver is someone who you physically need to accompany and attend all events with you. Caregivers are also required to register.

Question - Not Required - If you are a caregiver, who is the Hero with whom you will be traveling?

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Question - Required - Emergency Contact Name*:

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Question - Required - Emergency Contact Phone*:

Travel Information

Participants are required to arrive on Monday, March 23 and depart on Thursday, March 26. Once your registration is confirmed, Joanne Kramer from the American Lung Association will email you travel company information to book your flights.

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Question - Required - I will require hotel reservations*.

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Question - Required - Arrival Day/Date*:

Month

Day

Year

Question - Not Required - Departure Day/Date:

Month

Day

Year

Question - Not Required - I will be sharing a room with (full name). Please note: caregivers are required to share a room with their LUNG FORCE Hero.

I have special dietary considerations:

(Select one of the available choices or enter a different value.)
Question - Not Required -I have special dietary considerations: Click this to indicate that you will select an existing value. Tab to next input." I have special dietary considerations:
I have special dietary considerations: Click this to indicate that you will enter a new value. Tab to next input." I have special dietary considerations: Provide your answer here

Additional needs:

(Select one of the available choices or enter a different value.)
Question - Not Required -Additional needs: Click this to indicate that you will select an existing value. Tab to next input." Additional needs:
Additional needs: Click this to indicate that you will enter a new value. Tab to next input." Additional needs: Provide your answer here

Question - Not Required - If you are a LUNG FORCE Hero, have you already submitted a photo and your personal story to LUNGFORCE.org?

Question - Not Required - If yes, when did you submit? Please provide the link, if it is already posted on LUNGFORCE.org.

(Maximum response 255 chars, approx. 5 rows of text)

If no, please ask your local Lung Association staff contact to help submit your story.

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Question - Required - Do you use social media*?

Question - Not Required - I would be willing to share American Lung Association and LUNG FORCE-related information on:

	Facebook
	Twitter
	Instagram
	Snapchat

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Question - Required - Have you met with members of Congress, or congressional staff before*?

Question - Not Required - If yes, please elaborate:

Question - Not Required - If yes, what year(s):

	2019
	2018
	2017
	2016
	2015
	2014
	2013

Question - Not Required - If applicable, please provide the name of the Lung Association staff person completing this registration:

Question - Not Required - Staff person's email:

Question - Not Required - Staff person's phone:

Spam Control Text: Please leave this field empty

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