Federal Advocacy Day Speaker Requests

	Every year, hundreds of patients and professionals come together to talk to Members of Congress about important issues, like increased access to family building options and financial relief at RESOLVE’s Federal Advocacy Day, in partnership with the American Society for Reproductive Medicine (ASRM). Our advocates are passionate and dedicated people who return year after year and can tell you firsthand how empowering it is to participate in Advocacy Day. Sign up to request information about the Advocacy Day, and our advocates will work with you to schedule a day and time to provide a short presentation (10 15 min) about why getting involved with advocacy is so impactful and how you can start advocating for family building legislation on the federal level. Advocacy Day in on Tuesday, April 25, during National Infertility Awareness Week (April 23 29).
1.	Please fill out the following: * Name: First Name Required  Last Name Required      * Email: Required * City/State/ZIP: City Required State Required  ZIP Required    AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None   * Phone Number: Required   Yes, I would like to continue or start receiving email communication from RESOLVE.
2.	Question - Not Required - Company/organization name (if applicable): (Maximum response 255 chars, approx. 5 rows of text)
*3.	Question - Required - What is your relationship to infertility? Please select response I/We have been diagnosed with infertility I am a Professional who serves the infertility community I/We have resolved and have completed building my family I/We have decided to live without children I am a friend or family member of someone with infertility. Other
4.	Question - Not Required - How did you hear about federal advocacy day? (Maximum response 255 chars, approx. 5 rows of text)
5.	Question - Not Required - Do you have any specific questions about federal advocacy day? (Maximum response 255 chars, approx. 5 rows of text)
*6.	Question - Required - For scheduling your presentation, please provide your preferred day and time. Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923
*7.	Question - Required - What time would you like to meet?
*8.	Question - Required - About how many people to you expect to attend the presentation?
9.	Question - Not Required - Additional information? (optional) (Maximum response 255 chars, approx. 5 rows of text)
10.	Question - Not Required - Where did you hear about this Advocacy Day opportunity?

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