Join the Mott Children's Advocacy Initiative

Thank you for speaking up for children. The information in the following survey will help us to involve you in C.S. Mott Children's Advocacy Initiative efforts. We will use the information you provide to contact you when your voice is needed to improve the health and well-being of Michigan's kids.

Confidentiality Notice: The information you provide will not be shared with any other organization and will only be used to identify your legislators for the purpose of this program.

Ms. Mrs. Mr. Dr.  
First Name*: MI: Last Name*:
   
Home Address (to identify your legislators)  
Street Address*: 
City*: State*: Zip Code*:
Home phone:
 
Work phone:
 
E-mail*:
 
Fax:
 
     
Questions    

1. In what children's issues are you both interested and willing to contact elected officials about?
 
2. What actions would you be willing to take? Please check all that apply?
Writing letters to legislators Making phone calls to legislators Visiting legislators' offices to speak with them personally
Writing letters to the editor about children's needs Speaking to community groups about children's needs Offering to testify about children's needs at legislative hearings
Volunteering at a grassroots advocacy event    
 
3. What is your relationship with C.S. Mott Children's Hospital? Please check all that apply.
Board Member Employee Family member of a child served by the hospital
Volunteer Physician Nurse
Hospital Donor Pediatric Resident American Academy of Pediatrics member
Other (please specify):
 

4. Please list any legislators you know personally:
 

5. How did you find out about Mott Children's Advocacy Initiative?
     

Thank you!

Questions? Contact 734-936-9837

 

 

 

back to top