National MS Society: Survey - Pennsylvania Advocacy Story Bank Form

Pennsylvania Advocacy Story Bank Form

We're glad you want to share your story with us! Please take your time completing the form below. We can't wait to read your story!

Contact Information:

*

Name:

Title	First Required	Middle Required	Last Required	Suffix

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State/Province Required	ZIP/Postal Code Required

Country:

Phone Number:

Occupation:

*

Gender: Required

Remember me. What's this?

*

What is your relationship to MS?

(Select one of the available choices or enter a different value.)
Question - Required -

*

Question - Required - Share your story.

*

Question - Required - If you have any photos, you are asked to email them to Jennifer.Strayer@nmss.org. Do you have any photos to include with your story?

*

Question - Required - Do you have any personal relationships with any legislators?

Question - Not Required - If so, please describe the relationship. Be sure to include the names of who you know and how you know them.

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

*

Question - Required - Contact me about becoming an MS activist.

*

Question - Required - I hereby authorize the Pennsylvania Chapter Advocacy Network to use the above information for legislative advocacy and/or promotional purposes in printed materials such as press releases.

National Multiple Sclerosis Society

Accessibility Navigation:

Site Search:

Resource Navigation:

Primary Navigation:

Breadcrumb Navigation:

Pennsylvania Advocacy Story Bank Form

Pennsylvania Advocacy Story Bank Form

Footer Navigation: