BetterCaths Community Champion Registration Form

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Thank you for joining us!
We're incredibly grateful for your help in advancing this critical health equity movement for people with disabilities and chronic medical conditions.

We believe you deserve better when you self-cath. We're glad you do too!

The BetterCaths advocacy team is working to pass legislation to ban DEHP (a known carcinogen) in catheters used by Medicare & Medicaid beneficiaries. This is the first step of several steps in our long-term effort to improve catheter quality and access for people whose physical health depends on self-cathing.

To be featured as a BetterCaths Community Champion, please:

1.       complete the form below,
2.      include a good picture of yourself using your mobility device (social media worthy),
3. take the BetterCaths catheter user survey too (if applicable, link below)

*Your social media links are optional - we are adding them to your bio to help people connect with you online.

Please include org information below if you want to include the organization you represent as a BetterCaths organizational supporter. We will display the organization's logo that is used on its website.

Currently, our supporter program is for US residents and organizations only.

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* 1. Your contact information

Name *

Organization (include if you want to list this group as a BetterCaths supporter too)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Your bio: (3-4 sentences about your involvement in the disability community and accomplishments)

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* 3. Please give us a quote:
Why are you supporting BetterCaths initiative?

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* 4. Please give us a quote:
Why do you want to see DEHP banned in catheters?

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* 5. If you would like your organization included as a BetterCaths supporter, do you have permission to represent and include them?

Yes

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* 6. Your LinkedIn URL:

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* 7. Your YouTube URL:

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* 8. Your TikTok:

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* 9. Your Instagram:

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* 10. Your Facebook:

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* 11. Your Disability or Condition: (optional)

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* 12. Your Organization's website: (optional, if including org as supporter)

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* 13. What type of catheter do you use?

Intermittent catheter

Indwelling/ Foley / suprapubic catheter

I do not use a catheter

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* 14. Do we have your permission to share your name, condition, picture, bio and quotes (not email, city or phone) on our website & social media, when we spotlight you as a BetterCaths Community Champion?

Yes

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* 15. Do you agree to share/discuss BetterCaths resources on your social media to help other people learn and get involved? (please and thank you!)

Yes

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* 16. Please attach your picture here (social media worthy!)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 17. Is there anything else you would like to share with us?

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* 18. May the BetterCaths team contact you to keep you updated on our progress, and ways you can help?

Yes

If you use catheters (indwelling or intermittent), please also complete our
Catheter User Awareness Survey below. The data collected on this form will help us:
-- measure the lack of consumer awareness about Prop 65 warning labels catheters,
-- determine if healthcare providers are ethically informing patients about carcinogen warning labels on some catheters, and
-- educate legislators, Medicaid, and Medicare about the impact of bladder cancer within the catheter user community.

https://www.surveymonkey.com/r/PYLMCQJ

BetterCaths Community Champion Registration Form

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* 1. Your contact information

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* 2. Your bio: (3-4 sentences about your involvement in the disability community and accomplishments)

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* 3. Please give us a quote: Why are you supporting BetterCaths initiative?

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* 4. Please give us a quote: Why do you want to see DEHP banned in catheters?

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* 5. If you would like your organization included as a BetterCaths supporter, do you have permission to represent and include them?

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* 6. Your LinkedIn URL:

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* 7. Your YouTube URL:

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* 8. Your TikTok:

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* 9. Your Instagram:

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* 10. Your Facebook:

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* 11. Your Disability or Condition: (optional)

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* 12. Your Organization's website: (optional, if including org as supporter)

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* 13. What type of catheter do you use?

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* 14. Do we have your permission to share your name, condition, picture, bio and quotes (not email, city or phone) on our website & social media, when we spotlight you as a BetterCaths Community Champion?

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* 15. Do you agree to share/discuss BetterCaths resources on your social media to help other people learn and get involved? (please and thank you!)

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* 16. Please attach your picture here (social media worthy!)

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* 17. Is there anything else you would like to share with us?

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* 18. May the BetterCaths team contact you to keep you updated on our progress, and ways you can help?

* 3. Please give us a quote:
Why are you supporting BetterCaths initiative?

* 4. Please give us a quote:
Why do you want to see DEHP banned in catheters?