BCAN Grassroots Patient Advocate Registration

Thank you for your interest in becoming a BCAN Grassroots Advocate! Please complete the form below
so we can learn more about you and keep you informed about upcoming advocacy opportunities.

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1. What's your name?

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2. Mailing Address

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3. Phone Number

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4. Your preferred contact email for BCAN advocacy efforts:

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5. Are you a veteran?

Yes

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6. How would you like to engage with elected officials? Select all that apply.

In person meetings

Writing letters or emails

Phone calls

Virtual meetings

Other (please specify)

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7. If asked, are you willing to travel to DC to meet with legislators?

Yes

Depends

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8. How are you connected to bladder cancer?

Patient/Survivor

Caregiver

Supporter (friend, advocate, donor, volunteer, etc.)

Researcher/health professional

Other (please specify)

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9. Have you participated in advocacy before?

Yes, please describe your experience

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10. Are you interested in receiving advocacy training from BCAN?

Yes

BCAN Grassroots Patient Advocate Registration

Question Title

* 1. What's your name?

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* 2. Mailing Address

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* 3. Phone Number

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* 4. Your preferred contact email for BCAN advocacy efforts:

Question Title

* 5. Are you a veteran?

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* 6. How would you like to engage with elected officials? Select all that apply.

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* 7. If asked, are you willing to travel to DC to meet with legislators?

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* 8. How are you connected to bladder cancer?

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* 9. Have you participated in advocacy before?

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* 10. Are you interested in receiving advocacy training from BCAN?

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* 11. Please share any questions, comments, or concerns:

1. What's your name?

2. Mailing Address

3. Phone Number

4. Your preferred contact email for BCAN advocacy efforts:

5. Are you a veteran?

6. How would you like to engage with elected officials? Select all that apply.

7. If asked, are you willing to travel to DC to meet with legislators?

8. How are you connected to bladder cancer?

9. Have you participated in advocacy before?

10. Are you interested in receiving advocacy training from BCAN?

11. Please share any questions, comments, or concerns: