MA ACP - Day at the Statehouse Registration
Tuesday, March 26, 2019

(registration deadline - March 5, 2019)

Question Title

* 1. Name/Home address (to determine your voting district)

Name (Full name with degree(s) if appropriate) for name badge) *

Address *

Address 2

City/Town *

ZIP/Postal Code *

Email Address (preferred for confirmation) *

Phone Number (cell) *

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* 2. Where you work

Institution *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 3. ACP Number (if non-member click here: https://www.acponline.org/membership to join) - membership is required for participation.

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* 4. Please check one, I am a/an....

Attending Physician

Resident/Fellow

Medical Student

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* 5. Please check one

Registering for Morning & Afternoon Session

Registering for Morning Session Only

Registering for Afternoon Legislative Meetings Only

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* 6. Have you met with a legislator in the past?

Yes

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* 7. Have you received training on legislative advocacy?

Yes

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* 8. Physicians should participate in legislative advocacy.

Strongly Disagree

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

Strongly Disagree

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

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* 9. I am comfortable talking with legislators.

Strongly Disagree

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

Strongly Disagree

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

Question Title

* 1. Name/Home address (to determine your voting district)

Question Title

* 2. Where you work

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* 3. ACP Number (if non-member click here: https://www.acponline.org/membership to join) - membership is required for participation.

Question Title

* 4. Please check one, I am a/an....

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* 5. Please check one

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* 6. Have you met with a legislator in the past?

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* 7. Have you received training on legislative advocacy?

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* 8. Physicians should participate in legislative advocacy.

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* 9. I am comfortable talking with legislators.

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* 10. Comments...