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?*

YesNoMaybe
8. Select your residency year or fellow status*

CA-1CA-2CA-3FellowOther
9. Did you watch the online Resident Advocacy Champion Module?*

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

YesNoMaybe
11. On what date was the meeting?*

MonthDayYear
Date
12. Which lawmakers office did you meet with?*
13. Was the lawmaker in the meeting?*

YesNo
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?

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

YesNoMaybe
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?*

YesNoMaybe
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.
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