Resident Advocacy Champion Program

1. Full Name

First NameLast Name

2. Degree(s)

3. Email

example@example.com

4. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

5. State Component Affiliation

6. Member ID Number

7. Are you currently a resident or fellow?

8. Select your residency year or fellow status

9. Did you watch the online Resident Advocacy Champion Module?

10. Did you complete one in-person or virtual meeting with a lawmaker or their staff within the last year?

11. On what date was the meeting?

Date

12. Which lawmakers office did you meet with?

13. Was the lawmaker in the meeting?

14. Please tell us about who else was in the meeting, including the names of any lawmaker staffers:

15. Do you have any photos to submit?

16. Did you submit the meeting as an advocacy interaction?

If you have not logged the meeting as an advocacy interaction, please do so now by clicking here.

17. Do you certify that the above answers are correct, to the best of your knowledge?

Once submitted, you will recieve a digital "Resident Advocacy Champion" certificate. Please allow up to 30 days for this verification to be complete and this certificate to become valid.