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* 1. My Name

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* 2. My Email address

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* 3. My primary affiliation is with (check one):

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* 4. Additional affiliations with (check all that apply):

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* 5. Total number of Disability Policy Seminar participants in Hill meeting:

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* 6. Chamber:

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* 7. Member of Congress Last Name:

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* 8. State:

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* 9. Member's Interest/Involvement in disability issues:

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* 10. Member of Congress:

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* 11. Congressional Staff Member(s):

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* 12. Staff Member(s) name(s) and title(s) (type N/A if none present):

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* 13. Member's positions on our issues:

  Supports our position Does not support out position Neutral/non-commital Not discussed
Civil Rights and Community Living
Medicaid and Health Care
Social Security
Education
Federal Funding

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* 14. Additional comments (any information you provide will help us in our advocacy):

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