Ohio Campaign for Better Care Registration

1. Registration

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

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* 1. Yes! I have decided to join the Ohio Campiagn for Better Care.

As an individual

As an organization

Other (please specify)

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* 2. Please provide the following information:

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Organization affiliation:

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

Learn more about the health care reform law

Host a presentation about Campaign for Better Care in my community

Attend a story-telling workshop to learn how to effectively share my story

Attend a Writers’ Workshop to learn how to write powerful letters to the editor of my local newspaper

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

Attend an advocacy training to learn how to make a difference in my community

Attend a town-hall meeting in my community

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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* 4. 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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* 5. 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 Ohio Campaign for Better Care. We will be in touch with you soon!
Contact:
Julia Nielsen Bingman, Advocacy Coordinator
UHCAN Ohio, 404 South Third Street, Columbus Ohio 43215
614.456.0060 x 229
jbingman@uhcanohio.org
www.uhcanohio.org

100% of survey complete.