Children’s Action Alliance Lived Experience Leadership Academy (LELA) Survey

1.Please fill out your contact information

Name

Employer or Affiliation (if applicable):

Address

Address 2

City

State

ZIP/Postal Code

Email Address

Phone Number

2.Please briefly describe a health issue in Arizona, or a systemic barrier you have personally encountered, that concerns you and about which you would like to advocate.

3.Have you previously been part of any training related to healthcare or advocating for health change?

4.What interests you in applying for the Lived Experience Leadership Academy (LELA)?

5.Are you, or have you previously been, enrolled in Medicaid/AHCCCS/KidsCare or another public form of health insurance? Or have you been a caretaker of someone who has been?

6.Please list two references and their name, phone number, and e-mail. One reference can be a family member.

1st Reference

2nd Reference

7.Are you able to attend in-person and virtual (check those that apply)

Virtual

In person

Both

8.Do you have any dietary restrictions? Please be specific if so!