By filling out this form you will be added to the network of doctors nationwide who have indicated an interest in providing advocacy for young children with the support of Docs For Tots and it's partner child advocacy organizations. Your contact information will never be released directly to child advocacy organizations or others without consent.

Your Contact Information
* First Name:
* Last Name:
* Credentials:	Please Select OneDDSDMDDOMDMPHPhDOther If "Other" please specify:
* Organization:
* E-mail:
* Verify E-mail Address:
* Address:
* City:
* State:	Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
* Zip:
* Phone Number:	ext.
Fax Number:
*On the following scale, which best characterizes your current child advocacy efforts beyond your work in your primary office?
Very Active Somewhat Active Not at All Active
*Which statement best reflects your advocacy goals?
I am doing about as much as I feel I can I am active, but feel I could do more with the right support I am not so active, but would like to do more I am not very active at all, but would like to get started
*Your general and/or specific areas of interest include?
Child Abuse Children with Special Needs Foster Care Early Care and Education Early Literacy Environment Health Disparities Health Insurance Legislation/Policy Mental Health Parent Education Poverty Other
*In which area of focus did you complete your residency training?
Please Select OneFamily MedicineGeneral SurgeryNeonatologyObstetrics and GynecologyPediatricsPsychiatryOther If Other, please specify:
Spoken Languages other than English:
Cantonese French Korean Mandarin Spanish Vietnamese Other, please specify:
The following two questions on gender and race/ethnicity are voluntary fields. However, having the information makes it easier for us to respond to specific advocacy requests and we hope you will consent to filling them in.
Gender:
Female Male
Race/Ethnicity:
Please Select OneAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteMultiracialOther
*Are you a retired physician?
Yes No
*How did you hear about Docs For Tots?
Please Select OneDocs For Tots StafferE-mailInternet SearchReferred by a PeerSpecial Event or ConferenceOther If Special Event or Conference, please specify: