Medicaid Support Rally Sign-Up
Register to join and support the Medicaid Rally. Provide your details to help us coordinate a safe and successful event.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City and State of Residence
*
Do you have any accessibility needs or accommodations?
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How would you like to participate in the rally?
*
Marching/Walking
Holding signs/banners
Chant leader
Event setup/cleanup
Other
Are you affiliated with any group or organization?
Please Select
No affiliation
Health advocacy group
Community organization
Student group
Other
How did you hear about the Medicaid Support Rally?
Please Select
Social media
Friend or family
Flyer or poster
Organization email
Other
Do you need transportation assistance to attend the rally?
*
Yes
No
Sign Up
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