Please note that your name and contact information and interests may be shared with other advocates for purposes of networking; however, this information will not be given to elected officials or other policy-makers without your written consent.

E-Mail Address:

Name:

Voting Address:

City:

County

State:

Zip:

Day Phone:Please include area code (XXX.XXX.XXXX)

Evening Phone:Please include area code (XXX.XXX.XXXX)

Fax: Please include area code (XXX.XXX.XXXX)

I am a (please check all that apply):

Person with a disability
Family member of a person with a disability
Other:

Please check all the interest areas about which you want information to take action:

Adults' Issues, such as Community Options Program (COP), Community Integration Program (CIP), Family Care, Community Aids, Brain Injury Waiver, Medicaid Personal Care, waiting lists
Children's Issues, such as Birth to Three, Family Support, Long Term Care Redesign, Medicaid Personal Care, waiting lists
Accessibility such as ADA
Direct Service Workers (those who provide direct services to people with disabilities)
Education
Employment for people with disabilities
Housing
Mental Health/Mental Illness
Medicaid Services and Other Health Care
Respite Care
Transportation
Comments:

I am interested in taking these actions on the issues I have chosen (check all that apply):

Attending rallies
Contacting legislators (calling/writing)
Contacting other advocates
Meeting with legislators and other policymakers
Registering people to vote
Testifying at public hearings
Providing information to local media

Are you registered to vote:

Yes
No - Visit http://www.vote-smart.org/index.phtml to begin voting registration process.

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