Registrant Name and Contact Information

Thank you for filling out this form, which will serve as your registration for the Patients & Providers for Medical Nutrition Equity Coalition's Advocacy Day, which will be held on May 6-7, 2019, in Washington, DC. 

Please note that only ONE participant may be registered at a time. If you need to register children or other family members, please fill out a separate registration form for each person.  

Please list your name as you would like it listed on your name badge and any degrees that you would like listed.  It is critical that you use your VOTING address to register and not your business address.  We will collect any additional information about members of Congress you know personally or other relevant information on a different page.

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* 1. Participant Title

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* 2. Participant Last Name

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* 3. Participant First Name

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* 4. Degrees that you would like listed on your name badge

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* 5. Your VOTING Address

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* 6. If you are a health care provider, please provide the name of the institution and address at which you practice.

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* 8. Please select the category that best describes the registrant

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* 9. Is the registrant a child or caregiver for another registered participant and must be paired with that person for Hill meetings?

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