NVHR May 12 DC Rally Survey

1. NVHR Hepatitis Awareness Rally, Endorsement and/or Support

Please register to attend the rally. If you are not planning to attend, but your organization wants to endorse the rally, please fill out your contact information and then skip to questions 6 - 8 to indicate your interest in endorsing, supporting and/or honoring someone at the rally. Thanks!

*
1. Thanks for you interest in participating in the Hepatitis Rally! Please provide your contact information so that we may keep you up to date about logistics.

Thanks for you interest in participating in the Hepatitis Rally! Please provide your contact information so that we may keep you up to date about logistics. Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

2. Are you registering just for yourself or for more than one person

Are you registering just for yourself or for more than one person Just for myself

For myself and others

3. If you are registering for more than one person, how many people will you be bringing with you?

If you are registering for more than one person, how many people will you be bringing with you? one

two

three

four

five

more than 5

Other (please specify)

4. If you represent a community based organization, would your organization like to endorse the rally and have its information included on promotional materials

If you represent a community based organization, would your organization like to endorse the rally and have its information included on promotional materials Yes

Don't Know

5. Is your organization able to donate funds to help NVHR make this event more successful?
If yes, please make checks payable to:
The Task Force for Global Health, Inc
C/O NVHR
P.O. Box 1662
Rohnert Park, CA 94927
Thanks!

Is your organization able to donate funds to help NVHR make this event more successful? If yes, please make checks payable to: The Task Force for Global Health, Inc C/O NVHR P.O. Box 1662 Rohnert Park, CA 94927 Thanks! Sorry, not at this time

$50

$100

$200

$250

$500

More than $500

Other (please specify)

6. Would you like to honor a friend or relative who has lost their life to hepatitis B or hepatitis C by including their name and/or photograph on a rally sign? If yes, please tell us the person's name and birth and death date. Tell us if you have a photo of the person that you would like included on your sign.

Would you like to honor a friend or relative who has lost their life to hepatitis B or hepatitis C by including their name and/or photograph on a rally sign? If yes, please tell us the person's name and birth and death date. Tell us if you have a photo of the person that you would like included on your sign.

7. Would you be willing to help out with logistics the day of the rally?

Would you be willing to help out with logistics the day of the rally? Yes

Maybe - tell me more

If you can help, please provide us with your cell phone number. Thanks!

8. Is there anything else you would like us to know or do you have any additional questions for us?

Is there anything else you would like us to know or do you have any additional questions for us?

Thank you! We will be in contact regarding the rally logistics and plans.

NVHR May 12 DC Rally