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?

Question Title

* 2. Mailing Address

Question Title

* 3. Phone Number

Question Title

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

Question Title

* 5. Are you a veteran?

Question Title

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

Question Title

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

Question Title

* 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: