AAPM Advocacy Day Registration Registration Form First Name * Last Name * AAPM Membership Number * Email * Institution/Current Employer * Home Address * Home Address Home Address Home Address City City State/Province State/Province Zip/Postal Zip/Postal Home Address State of Residence * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code of Residence * Area of Medical Physics Focus * Years in Practice * Student / Trainee / Resident Post Doc 1- 8 years 9 - 15 years Over 15 years What Interests you about participating in advocacy? Do you have past advocacy experience, either in medical physics or other fields? Yes No Have you developed relationships with any United States Representatives or Senators? Is there anything about your work you'd wish to share (i.e., novel research, federal grants, clinical developments, improved patient experiences)? What key priorities do you think should be highlighted in medical physics advocacy? Are there specific issues within medical physics you feel should be addressed in upcoming discussions? Captcha Submit If you are human, leave this field blank. Terms and Conditions
