Pennsylvania Campaign for Better Care Registration

1. Registration

We are pleased that you have decided to join the Pennsylvania Campaign for Better Care. Please complete the following questions to join and you will receive follow up within one week from the Consumer Health Coalition about the work of the campaign.

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* 1. Please provide the following information:

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Organization affiliation:

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* 2. I would like to (Please check as many as you like):

Learn more about health care reform

Host a casting call and/or a presentation about Campaign for Better Care in my community

Speak to my legislator about the issues of the Campaign for Better Care by telling my story

Become a spokesperson for the Campaign for Better Care in Pennsylvania

Write letters to the editor

Help talk to older adults about their stories

Share my story (you may share your story in the following questions)

Other (please specify)

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* 3. Tell us your story. What challenges do you experience with the health care system? Is the current system serving your needs or those of the person you care for? What impact has your experience had on your daily life?

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* 4. Tell us what you need most from our health care system to meet your needs or those of the person you care for:

Thank you for signing up for the Pennsylvania Campaign for Better Care. We will be in touch with you soon!

Contact:
Ted Zimmer
Community Organizer
Consumer Health Coalition
www.consumerhealthcoalition.org
650 Smithfield St. Suite 2130
Pittsburgh, PA 15222

100% of survey complete.