Annual Advocacy Day Application

Thank you for your interest in DPC’s Annual Advocacy Day. Please fill out the form below to submit your application.

Advocacy Day Application

Prefix(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone(Required)

Is the primary phone entered a cell phone?(Required)

Secondary Phone

Is the secondary phone entered a cell phone?

Email Address(Required)

Which of the following best describes you?(Required)

Which dialysis provider do you use?(Required)

Are you attending any other kidney group's advocacy day in 2023?(Required)

(e.g. AKF, NKF, AAKP, etc.)

Please list the names of the groups whose advocacy day you are attending in 2023:(Required)

Have you ever attended DPC Annual Advocacy Day?(Required)

Have you ever interacted with Members of Congress or their staff?(Required)

If yes, please provide name and details:(Required)

Have you ever advocated for an issue before?(Required)

If yes, please explain:(Required)

If chosen to participate, do you prefer in-person or virtual?(Required)

Your interest:(Required)

Why do you want to participate in DPC's Congressional Advocacy Day?

Your story:(Required)

How long have you (or your family member) been on dialysis? What has your experience with dialysis been? How has it impacted you or your family?

Attachments

If you would like to attach any additional documents (e.g. resume, CV, letters of recommendation), please attach those here:

Drop files here or

Max. file size: 200 MB.