NPAF ELITE President's Council Signup Form

Please enter your title.
Enter your primary Phone number
Please enter a secondary telephone number at which you can be reached.

The information requested below is voluntary.  Our intent is to have a diverse roster of members who represent the US population, varied political opinions and expertise with media, policy and politics.  This information will not be shared outside the National Patient Advocate Foundation or its companion Patient Advocate Foundation.

Tell us a little about yourself:
Are you male or female?
Please select your marital status
Please select your ethnicity or race
Are you currently employed?
Are you a registered voter in the United States?
Please select your highest level of education
Have you ever (please check all that apply)...
Written or called any politician about healthcare?
Attended a political/policy event?
Attended a public meeting or hearing on health care?
Served on a committee for a local organization?
Served as an officer for a club or organization?
Written a letter to the editor or called a live radio/TV show?
Signed a petition in support of/opposition to an issue?
Been interviewed on television or radio?
Volunteered for a political campaign or party?
Made a political donation/contribution?
Held or run for any political office?
Been active in a group trying to influence government?
Do you know personally any elected officials?
miles
Approximately how many miles do you live from your state capital?
Who referred you/how did you learn about this application?
Tell us about your connection to health care:
Have you ever used the services of the Patient Advocate Foundation?
How familiar are you with health care delivery in this country?
Which of the following have you or a close family member relied on for health coverage (check all that apply):
Have you or a family member ever had difficulty obtaining health coverage or access the medical care that you need? Please describe:
Are you willing to share your experiences with health care and the health care system?
Is there anything else you’d like to tell us?

If you are not submitting online, please return by November 30 to:
Joseph LaMountain, National Patient Advocate Foundation, 725 15th Street #1000, Washington, DC 20005.
Questions?  Please contact Joseph LaMountain at 202.288.5124 or joe.lamountain@patientadvocate.org