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WALTCOP Lobby Day Registration
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WALTCOP Lobby Day Registration
Name
(Required)
First
Last
Residential Address
(Required)
Street Address
Address Line 2
City
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State
ZIP Code
Phone
(Required)
Email
(Required)
I am a(n)... (check all that apply)
(Required)
Current Certified LTC Ombuds
Long-Term Care Resident
Resident Friend/Family/Representative
Advocate/Supporter
Other
You selected "Other." Please specify your role:
(Required)
If known, What is your State Voting District?
Do you want a sack lunch?
(Required)
Yes
No
Who is your contact in case of an emergency? Please include their name, relationship, and phone number.
(Required)
IMPORTANT: State LTCOP will make appointments for you!
Participation in LTC Ombuds Advocacy Day includes meeting with your legislators. If you are a long-term care ombudsman, resident or a resident family member, the State LTCOP will schedule your appointment for you. This is to pair advocates and coordinate with the staff of elected officials by voting district for the meetings. If you are not a long-term care ombudsman, resident or resident family member, the LTCOP won't automatically make an appointment for you. We will send your appointment to you as soon as it is booked. A final list of the scheduled appointments will be emailed to each registrant by January 26. You will receive an electronic packet of information in advance of January 28. We will provide the same packet, with your appointment in writing on the day of the event- January 28.
IF YOU DO NOT WISH US TO SCHEDULE AN APPOINTMENT FOR YOU PLEASE INDICATE HERE BY CHECKING THIS BOX:
I do NOT wish State LTCOP to schedule appointments for me
Comments? Questions? Do you have any needs we should know about?
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