Heart on the Hill Lobby Day: May 15, 2013

Registration

Thank you for registering for the Heart on the Hill Lobby Day at the Rhode Island State House on May 15, 2013. Please complete all of the following questions so that we can match you with your legislators. Registrations must be received by May 1, 2013.

Please note that Rhode Island has a part-time legislature. We will plan to catch your legislators in the House and Senate chambers prior to the floor sessions. Training will be provided and staff will be on hand to assist.

Question Title

* 1.
Please complete the following information. You MUST provide your home address so that we can match you with your elected officials. Cell phone numbers will only be used to reach you on May 15, 2013. If you would like to skip a section, please type in that section "n/a."

First Name:

Last Name:

Address:

City:

State:

Zip code:

Email Address:

Cell Phone Number:

Telephone Number:

Question Title

* 2.
Please list the name(s) of anyone that will be attending the event with you.

First Name:

Last Name:

Relationship:

First Name:

Last Name:

Relationship:

First Name:

Last Name:

Relationship:

Question Title

* 3.
Please write a brief description of your personal story of how you have been impacted by heart disease and stroke, so that we can get to know you better. Your written story may be included in packets on the day of the event and possibly used for media promotion of the event.

Question Title

* 4.
Do you personally know an elected official? If yes, please include the name(s) below.

Thank you for registering for the Heart on the Hill Lobby Day! Please let us know if your schedule changes and you are unable to attend. We look forward to seeing you on May 15!

Question Title

* 1. Please complete the following information. You MUST provide your home address so that we can match you with your elected officials. Cell phone numbers will only be used to reach you on May 15, 2013. If you would like to skip a section, please type in that section "n/a."

Question Title

* 2. Please list the name(s) of anyone that will be attending the event with you.

Question Title

* 3. Please write a brief description of your personal story of how you have been impacted by heart disease and stroke, so that we can get to know you better. Your written story may be included in packets on the day of the event and possibly used for media promotion of the event.

Question Title

* 4. Do you personally know an elected official? If yes, please include the name(s) below.

* 1.
Please complete the following information. You MUST provide your home address so that we can match you with your elected officials. Cell phone numbers will only be used to reach you on May 15, 2013. If you would like to skip a section, please type in that section "n/a."

* 2.
Please list the name(s) of anyone that will be attending the event with you.

* 3.
Please write a brief description of your personal story of how you have been impacted by heart disease and stroke, so that we can get to know you better. Your written story may be included in packets on the day of the event and possibly used for media promotion of the event.

* 4.
Do you personally know an elected official? If yes, please include the name(s) below.