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2012 Virginia Advocacy Survey

2012 Virginia Advocacy Survey

 

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We want to hear from you!


Your voice can help set the direction for future services and support; drive important

public policy initiatives and provide the critical information needed to leverage resources.

Please complete this short, confidential survey to provide us with a snapshot of who you are

and the advocacy issues that are important to you. 

 

Your answers will only be used for the purpose of focusing our advocacy efforts in Virginia.

Providing your name and address are optional -

 

HOWEVER, if you choose to share your story and are comfortable with the National MS Society

using your story for publication, please provide your name, phone number and/or email address

in the text field.

 
If you would like assistance with this survey or have any questions,

please call 804-591-3048.

 

Thank you for JOINING THE MOVEMENT!

  

  

*
Question - Required - What is your connection to MS or the National MS Society? Check all that apply.

 
Question - Not Required - Approximately how long have you (or the person you care about) been diagnosed with MS?






 

Respite Care (professional short-term help to give caregivers a break from providing care)

 


 

(Maximum response 255 chars, approx. 5 rows of text)

 

Transportation

 


 

(Maximum response 255 chars, approx. 5 rows of text)

 

Housing

 


 

(Maximum response 255 chars, approx. 5 rows of text)

 


 

(Maximum response 255 chars, approx. 5 rows of text)

 

Click here to learn more about the Livable Home Tax Credit

 

Health Care

 


 

(Maximum response 255 chars, approx. 5 rows of text)

 


 

(Maximum response 255 chars, approx. 5 rows of text)

 

MS and Public Policy

 

(Maximum response 255 chars, approx. 5 rows of text)

 

Thank you for taking the time to complete this important survey.

Are you ready to do something about MS NOW?

Join our statewide advocacy efforts and provide your name and contact information below.

*
Question - Required - Are you willing to join our statewide advocacy efforts? Check the box(es) for ALL of the following ways you are willing to help.

*
Question - Required - What National MS Society Chapter are you a member of?






  I am ready to get involved! Please contact me about advocacy opportunities using the information below:

If you have previously registered, please to prepopulate your information.

 

Name:

 

 

 

     

 

 

 

 

City/State/ZIP:

 

    

 

 

 


 

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   Please leave this field empty