Pediatric Legislative Day Registration

Please complete and submit by Tuesday, February 12, 2025.

First Name

Last Name

Designation

Example: MD, FAAP etc.

Organization Affiliation

Home Address

City

Home Zip Code

Your Email

Your Daytime phone number

(###)

###

####

Your cell phone number

(###)

###

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Please check below which components you will attend

21st Legislative Day on Wednesday, February 19, 2025

Tuesday, February 18, 2025 dinner with a legislative committee

I can't attend either but I would like to donate to the Chapter's 2025 advocacy efforts

Yes, I will contribute to the Chapter's 2025 advocacy efforts with a tax-deductible contribution of:

Please click submit above BEFORE making any contributions (click button below to donate).

donate now