2020 Advocacy Application

Please complete this application to express your interest in participating in Washington Days or Nevada's State Advocacy Day.

Please read the following information to understand the goals and process:

·       Our goal is to have at least 20 individuals from across the State participate.

·   Participation will be via zoom.

· Selected individuals will be notified by February 1st.

·       All individuals seeking to participate in either Washington Days (March 3-5, 2021) or the Nevada State Advocacy Day (March 15-19, 2021) must submit a form so that we can start the process of scheduling appointments with their representatives.

Selection Criteria: The Nevada Chapter’s Advocacy Committee will be drafting talking points for the NV Advocacy Day that focus on key issues effecting access to care and targeting key decision makers within the legislature. Individuals will be prioritized for participation based on:

·       Participation in advocacy trainings held throughout the year in 2020 & 2021

·       Advocacy story that highlights issues included in talking points

·       Constituents of targeted elected representatives (Live in the district of a key decision maker)

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* 1. Commitment: Please check each line to indicate you understand that by applying, you commit to fully participate in all activities:

Attending 3 one-hour trainings to be held on February 10, 17 & 24 at 4 pm

Attending Training & Check-In Session the morning of your scheduled State & Washington Meetings

Attending scheduled meetings with legislative members

Attending debrief sessions after meetings with legislative members

Sharing "your story" and prepared talking points only

Completing follow up items (thank you, social media tag, etc.)

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* 2. Name on Nevada ID:

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* 3. Your contact information:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Attendee is...

Person with a bleeding disorder

Parent/guardian of a minor child with a bleeding disorder

Carrier of a bleeding disorder

Unaffected advocate for person with bleeding disorders

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* 5. Please share any challenges you or your family have faced in accessing care of medications:

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* 6. Please share issues you are concerned about accessing care or medications:

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* 7. I certify that the information I have submitted is true and accurate to the best of my knowledge. In the event there is a change to the information I have provided on this application, I will notify the Nevada Chapter within 15 days.

Name