Advocacy

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Visit the Promise to Remember Me site to read our blog and get the latest updates on the campaign at jdrfpromise.org.

2011 Advocate Survey

1. Please review the contact information that we have on file for you. Please make any necessary changes and note below how you would prefer us to contact you in the future.

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Name:

 

 

 

 
       

 

 

 

City/State/ZIP:

 

    

 

 

 

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Date of Birth:



 


1. Please tell us which of the following issues is the most important to you. Place a 1 next to the issue that is most important, a 2 next to the issue that is the next most important, and so on.
 


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3.
Question - Not Required - Which of the online social networks below do you use regularly?
Please make up to 5 selections from the choices below.

4.
Question - Not Required - Are you currently following JDRF Advocacy's updates through any of the social networks/tools listed below? (check all that apply)
Please make up to 4 selections from the choices below.

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(Maximum response 255 chars, approx. 5 rows of text)
7.
Question - Not Required - Do you know, personally or professionally, any of your federal legislators (or a member of their staff) or key federal officials listed below? If so, please describe the nature of the relationship.
Please make up to 6 selections from the choices below.






8.
Question - Not Required - Please provide the nature of your connection to type 1 diabetes. (check all that apply)
Please make up to 6 selections from the choices below.

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(Maximum response 255 chars, approx. 5 rows of text)
 

Thank you for your participation!
   Please leave this field empty