Advocacy Survey - Formstack

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Advocacy Survey

Name*

First Name*

Last Name*

Organization

Address*

State

ZIP Code

Email*

Phone*

I am a:

Health Conditions you or your family deal with:

Allergies Asthma 特应性皮炎(湿疹) Eosinophilic disease (asthma, esophagitis, gastrointestinal disease, etc.) FPIES Hives or chronic hives (urticaria) Other allergic conditions Nasal polyps and chronic rhinosinusitis

Please identify which advocacy issue(s) you are interested in supporting:

Access to medical care and treatment Federal funding for programs that benefit those with asthma and allergies Environmental Health/Climate Change/Air and Water Quality Reduction of risk for allergy and asthma emergencies (anaphylaxis, asthma attacks) Care and accommodations for students with asthma and allergies Other

(Check all that apply)

Other Advocacy Interests:

Please describe your availability

One-time event 1 – 5 hours a month 10-20 hours a month Ongoing commitment count me in

[check all that apply]

I am interested in attending Allergy and Asthma Day on Capitol Hill in May (in person or virtually)

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