2016 Family Leadership Conference Registration

Family Leadership Conference: Expanding Our Reach, Impacting the Future
Reception: Champions for Children's Health
March 29-31, 2016
Click here for conference details including payment information and agenda

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* 1. Contact Information:

Name *

Organization

Address *

Address 2

City/Town *

State *

ZIP *

Email address

Work Phone *

Cell Phone

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* 2. (Optional) Please indicate your race:

American Indian or Alaskan Native

Asian

Black

Pacific Islander

White

Other Race

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* 3. (Optional) Is your ethnicity Latino or Hispanic?

Yes

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* 4. (Optional) Please indicate your primary language:

English

Spanish

Other:

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* 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:

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* 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

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* 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

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* 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)

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* 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:

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* 10. Aside from dietary needs, do you need any specific accommodations at the meeting?

Yes

If yes, please specify:

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* 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

I am not sure at this time.

Comments:

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* 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

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* 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)

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* 14. Is this your first time attending a national family leadership meeting with Family Voices?

Yes

Comments

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* 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.

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* 16. Are you planning to attend the Champions for Children's Health reception on Tuesday, 3/29, 5:30pm-7:30pm?

Yes

Comments

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* 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.