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.

    Personal Information
    Please provide us with your basic information so that we may contact you regarding the status of your application.
    Prefix*

    Is the primary phone entered a cell phone?*

    Is the secondary phone entered a cell phone?*

    Which of the following best describes you?*

    If you are a current dialysis patient, which dialysis provider do you use?

    Are you attending (virtually or in-person) any other kidney group's advocacy day in 2022? (e.g., AKF, NKF, AAKP, etc.)*

    Please list the names of the groups whose advocacy day you are attending in 2022:*

    Have you ever attended DPC's Annual Fly-In?*

    If yes, when?*

    Have you ever interacted with Members of Congress or their staff?*

    If yes, please provide names and details:*

    Have you ever advocated for an issue before?*

    If yes, please explain:*

    Are you willing to participate in a virtual advocacy day (i.e., phone meetings)?*

    Essay Questions

    Your interest: Why do you want to participate in DPC's Annual Advocacy Day?*

    Your story: How long have you 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.