AA Form Testing Page

Thank you for your interest in educating your elected officials about PH. Meetings with members of Congress and their staff are a powerful way to build PH allies in Congress.

Please provide the information requested below if you would like PHA to schedule a meeting for you. Note that meetings may be with your U.S. representative, one of your U.S. senators or their health staff based on availability. All visits are valuable and offer an opportunity to influence policy that matters to the PH community.

Name *

First

Last

Email *

Address

Address Line 1

City

State

Zip Code

Phone *

What is your connection to PH?

Patient
Family/Friend
Medical professional
Other

Do you know any members of Congress personally or have a specific Congressperson you would like to visit? *

What type of virtual visit do you prefer?

Virtual visit by video
In-person visit at the nearest Congressional district office
I am open to either type of visit

I am willing to meet with more than one member of Congress or their staff.

Yes
No

Preferred dates and times for your visit(s)

Date and Time 1

Date

Time

Date and Time 2

Date

Time

Date and Time 3

Date

Time

Date and Time 4

Date

Time

Date and Time 5

Date

Time

I would like to receive coaching from a PHA staff person to help me prepare for my visit.

Yes
No

Comments

CONTACT US FORM

Test – On the Road Registration Form

Test – Virtual Advocacy Visit Signup Form

Title