Medicaid Matters Survey

Thank you for completing this survey. By doing so, you agree to allow Survival Coalition of WI, its member organizations, and The Arc Wisconsin to share your stories on social media and with policymakers.

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* 1. First Name

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* 2. Last Name

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* 3. City you live in.

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* 4. Zip Code

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* 5. Email Address

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* 6. Tell us how your life is now. (ex. I live in my own home in the community, not in an institution, I work at ..., I volunteer etc.)

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* 7. How do you use Medicaid? Medicaid makes it possible to... (ex. I need a caregiver to get me in and out of bed, help support me at my job, to get medications, to make and go to appointments, and other things.)

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* 8. If Medicaid is cut, and I have less support than I have now: I (or the person I support)will not be able to: (ex. Live where I want to live, get out of bed, get to work, keep up on medications, etc.)

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* 9. I give permission for Survival Coalition, its members, and the Arc Wisconsin to share this information publicly.

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* 10. Willyou be registering for Disability Advocacy Day? If Yes, a copy of your story will be provided for you to give your legislators.

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* 11. Please upload a photo of yourself or the person you support.

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