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Interest Form
Welcome and thank you in advance for your help in making medical aid in dying a legal option in Arizona!
Please complete the information requested below to help us understand how we can best satisfy your interests.
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First Name
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Last Name
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Email
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Address
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City
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State
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Zip Code
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Phone (primary)
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If located in Arizona, which city do you live closest to?
Phoenix
Flagstaff
Tucson
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Which State Legislative District (LD) are You In? Refer to
http://azredistricting.org/districtlocator/
for assistance.
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We want to be respectful of the time you might commit. Please indicate how much time you can initially donate to volunteering
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1 hour a month
4-10 hours a month
>10 hours a month
Unable to volunteer, but keep me informed
Do not send any emails and no calls
Please check the area(s) below that best match your skills and areas of interest. You will be contacted as soon as possible to discuss specific volunteer opportunities.
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Public Education and Events
Advocacy / Legislation: Interfacing with Local and State Government
Sharing the End-of-Life Story of You or a Loved One
Training, Organizing or Managing of Other Volunteers
Communications (writing, newsletter editing, media relations, PR)
Engagement with Physicians and Other Medical Professionals
Technology / Administration
Other:
Required
Everyone's contribution is important. We may have some specific needs in the areas below, so please indicate if you have experience you can share
Physician
Attorney
PR / Press
Politics
Web site design or Social Media
Technology / Administration
Other:
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