Exit this survey 2016 Family Leadership Conference Registration Family Leadership Conference: Expanding Our Reach, Impacting the FutureReception: Champions for Children's HealthMarch 29-31, 2016Click here for conference details including payment information and agenda Question Title * 1. Contact Information: Name * Organization Address * Address 2 City/Town * State * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP * Email address Work Phone * Cell Phone Question Title * 2. (Optional) Please indicate your race: American Indian or Alaskan Native Asian Black Pacific Islander White Other Race Question Title * 3. (Optional) Is your ethnicity Latino or Hispanic? Yes No Question Title * 4. (Optional) Please indicate your primary language: English Spanish Other: Question Title * 5. Please indicate all roles that apply to your participation in this event: Parent/Family Member F2F or FV SAO Staff State MCH Staff Federal MCH Staff Family Voices Board Member Health Provider/Professional Education Provider/Professional Youth Other: Question Title * 6. If you are a family leader, what is your level of experience? I consider myself a new family leader I am a family leader with some experience I consider myself an experienced family leader Comments Question Title * 7. A list of participants and contact information will be made available to meeting attendees to facilitate on-site communication and networking. The list will contain Name, Organization, State, Email (optional), and Cell Phone (optional). Please indicate your preferences for this list: (check all that apply) Include my email address Include my cell phone I do not want to be on the list Question Title * 8. Which hotel will you be staying at? I do not require hotel accommodations for this event. Even Hotel Bethesda North Marriott I am not sure at this time. Other (please specify) Question Title * 9. Please tell us about your dietary needs: (Check all that apply) I do not have any specific dietary needs Vegan Vegetarian Gluten-free Kosher I have other food allergies (please specify in comments) Other (please specify in comments) Comments: Question Title * 10. Aside from dietary needs, do you need any specific accommodations at the meeting? Yes No If yes, please specify: Question Title * 11. We anticipate that we will have room for a display area. This is an opportunity to showcase products/materials related to the work of your organization to MCHB staff and other family organizations/leaders. Is your organization interested in displaying any materials? (We will update you on how much space is available.) Yes No I am not sure at this time. Comments: Question Title * 12. While in the area, we encourage you to meet with your Members of Congress to educate them about the challenges facing families of CYSHCN and the important work of the F2F/SAO in your state. These meetings would be purely educational; no lobbying will be involved. The Family Voices policy team is available to help you prepare for Hill visits and can help identify someone experienced with Hill visits to accompany you, if needed. Please check all that apply: I would like assistance in planning Hill visits. I would like someone to accompany me on my Hill visits. I am planning to make Hill visits, and do not need assistance. I am willing to accompany someone who would like assistance with their Hill visits. I am not currently planning to make Hill visits. (Please indicate the reason in the Comments.) Comments Question Title * 13. If you are planning to make Hill visits, which day? Tuesday before the reception Thursday after the meeting ends Not sure yet Other (please specify) Question Title * 14. Is this your first time attending a national family leadership meeting with Family Voices? Yes No Comments Question Title * 15. Please note any states, organizations, or individuals that you are particularly interested in connecting with at the meeting, and we'll do our best to help facilitate these connections. Question Title * 16. Are you planning to attend the Champions for Children's Health reception on Tuesday, 3/29, 5:30pm-7:30pm? Yes No Comments Question Title * 17. Is there anything else you would like to tell us? Thank you! We look forward to seeing you at the meeting. Please click here for registration fee payment instructions, if applicable. Done