Complete this form to join Disability Rights Education & Defense Fund (DREDF) in our continued efforts to ensure access to affordable healthcare, Medicaid, and supports and services needed to live in our communities, including housing. We are collecting stories to share as we meet with officials in Washington DC, and to amplify on social media. Please share some basic information, and we will reach out to you about how you can get involved! You can also use this form to share your story.
Participant information

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* 1. Name:

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* 3. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 4. Phone number:

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* 5. Where do you get your healthcare coverage? (mark all that apply)

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* 6. Do you identify as disabled, Deaf, and/or chronically ill?

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* 7. Tell us about yourself. Include your age (if you'd like), race/ethnicity, pronouns, a brief description of your disability, and any equipment you use (like a wheelchair, ventilator, etc.).

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* 8. Do you experience barriers to health care, housing or other supports or services needed to live in your community? If so, what are they?

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* 9. If you purchase insurance on the exchange, have your premiums gone up? By how much? Do you rely on tax credits to make your plan affordable?

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* 10. What do you want Congress and decision makers to know about Medicaid, your health insurance, housing or other support or service? What message do you have for those who are making cuts to critical programs?

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* 11. Do you have any questions or comments?

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* 12. How would you like to get involved? (mark all that apply)

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* 13. I can share my story. DREDF participates in rallies and events like the past 60 Hour Protect Medicaid Vigil. During events, we read stories from people around the country about why Medicaid is important to them, including messages to Congress. We also submit stories to Congressional offices that are fighting for our access to necessary supports and services like Medicaid, affordable healthcare, and housing. You can use the questions earlier in the survey as a guide for your story and include anything else you would want policymakers to hear.
Please let us know if you would like your name included or want to remain anonymous. We will follow up if we use your story or have submitted it to a Congressional office. If there is not enough space, please email your story to media@dredf.org.

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* 14. How may we share your story?

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* 15. Where can we share your story?

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