IMPACT COPD Public Registration

Interest Form-Participant Details

Thank you for your interest in attending IMPACT COPD on June 18-19, 2019. Space is extremely limited for this important event. Please provide a few details using this form to indicate your interest in attending and a COPD Foundation staff member will get back to you within 3 days to discuss the event further and secure your spot.

*1.Please enter your contact information.(Required.)

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

2.With which category do you identify?

I am a person living with COPD

I have a loved one or family member with COPD

I am a healthcare professional

Other (please specify)

3.How long have you or your loved one been living with COPD?

less than one year

1-3 years

3-5 years

5-8 years

8-11 years

11-15 years

more than 15 years

I am a health care professional

4.Have you participated in any of the following advocacy activities? (check all that apply)

Called an elected official (State or Federal)

Emailed an elected official (State or Federal)

Signed a petition

Visited an elected official

Attended a Congressional "Hill Day"

Media training

Advocacy training

State based advocacy days

Testified at a state or federal committee hearing

Presented at a conference about your experiences with COPD

Public speaking about a topic other than COPD

Participated in an advisory committee related to COPD topics

Other (please specify)

5.Why do you want to participate in the training workshop and congressional visits?

6.How would you take the information you learn at the workshop and apply it when you return home?

7.Are you willing to complete follow up activities after the workshop and congressional visits? Examples include writing thank you notes to the staff you met with during your congressional visits, etc.

Yes

8.Have you ever considered becoming a State Captain?

Yes

I am a current State Captain

Current Progress,

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