Survey - 2023 LUNG FORCE Advocacy Day Registration

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2023 LUNG FORCE Advocacy Day Registration

*Required fields marked with an asterisk

Contact Information:


*	First Name: Required
*	Last Name: Required
	Professional Suffix:
*	Email: Required
*	Address Line 1: Required
	Address Line 2 (Optional):
*	City: Required
*	State: Required
*	Zip Code: Required
*	Phone Number: Required
	Yes, I would like to receive e-mail from the American Lung Association
	Yes, I would like to receive postal mail from American Lung Association
	Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy

*

Question - Required - Cell Phone:

Question - Not Required - Best Number to Reach You During the Daytime:

Question - Not Required - Current Voting Address (If different than home address above)

*

Role:

(Select one of the available choices or enter a different value.)
Question - Required -Role: Click this to indicate that you will select an existing value. Tab to next input." Role:
Role: Click this to indicate that you will enter a new value. Tab to next input." Role: 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 a LUNG FORCE Hero, do you require a caregiver to assist you? Caregivers are also required to register.**

Question - Not Required - Caregiver Name:

Question - Not Required - Caregiver Emergency Contact Name:

Question - Not Required - Caregiver Emergency Contact Phone:

Question - Not Required - What mode of communication works best for you? (Select all that apply)

	Email
	Texting
	Phone Call

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

Question - Not Required - What days are generally more open for you to join training webinars/calls ? (Select all that apply)

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday

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

	Facebook
	Twitter
	Instagram
	Snapchat

Question - Not Required - What time of day is generally more open for you to join training webinars/calls? (Select all that apply)

	Mornings (8am-12pm ET)
	Afternoons (12pm-5pm ET)
	Evenings (5pm-9pm ET)

Question - Not Required - How will you be accessing the training webinars? (select any that apply)

	I have a desktop computer
	I have a laptop computer
	I have a tablet (Ipad)
	I have a smartphone
	Other please explain

If Yes Please give the name of the Hero/Caregiver that you will be traveling with.

*

Question - Required - Do you use social media?

*

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

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

	2021
	2020
	2019
	2018
	2017
	2016
	2015
	2014
	2013

Question - Not Required - Do you have personal contacts in your members' offices?

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

Question - Not Required - How are you willing to share your story and photo in (check all that apply):

	With your Members of Congress
	Video
	Blog
	Media Interview
	On Lung.org

Question - Not Required - Why are you a LUNG FORCE Hero?

Question - Not Required - Why do you want to be a part of 2023 LUNG FORCE Advocacy Day?

Question - Not Required - How can people best support lung cancer survivors during the ongoing COVID-19 pandemic?

Question - Not Required - What advice would you give to someone who is newly diagnosed with lung cancer?

Question - Not Required - What Questions do you have for us about Advocacy Day?

Thank you so much for taking the time to complete this survey. Please contact Lfad@lung.org if you have any questions.

Travel Information

Participants are required to arrive on Monday, March 27 and depart on Thursday, March 30
Once your registration is confirmed, you will be emailed travel company information to book your flights.

Question - Not Required - I will require hotel reservations

Question - Not Required - Arrival Day/Date:

Question - Not Required - Departure Day/Date:

Question - Not Required - Full name of person I'll be sharing a room with (Please note: caregivers are required to share a room with their Hero):

Question - Not Required - I will not require hotel reservations.

*

Dietary Restrictions:

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

Question - Not Required - I have additional needs (such as oxygen, wheel chair):

*

Question - Required - For security reasons, please enter the following text in the box below:

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Spam Control Text: Please leave this field empty

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