Thank you for your interest in the KPP grassroots program.
Please fill out the following form.

please note: all fields marked with an * are required

Date:
*Full Name and Credential:
*Address:
*City:
*State:
*Zip Code plus 4:	+
Don't know the plus 4? Look it up at http://zip4.usps.com/zip4/welcome.jsp
*County of Residence:
*Telephone #:
*Email Address:
*ADA Member Number :
*PADA District:	Central Lehigh Valley Northeast Northwest Philadelphia Pittsburgh
*Current Employer:
*Area of Practice:
*Total Years in Practice:
Areas of Expertise Outside Practice Area:
Certifications (i.e. CDE, Personal Training, Health Education, Weight Management, etc.)
Please list the following:
Federal Representative:
State Representative:
State Senator:
Don't know your state legislators? Look them up with your zip code plus 4
We are interested in developing a network of nutrition policy experts to whom we can go when a relevant policy issue arises. Please answer the following questions:
*Have you ever been involved with any health-based committees or task forces?	please write yes or no
if yes, please list:
*Do you know or work with anyone involved with any state or local health-based committees or tesk forces?	please write yes or no
if yes, what is their involvement?
if asked to participate in a steering committee or task force, what areas would interest you most? (i.e. school nutrition, cardiovascular disease, obesity, etc.)?
*Do you personally know any state or federal legislators?	please write yes or no
if yes, who do you know and how do you know them (not patients, please)?
*Have you ever visited with your state or federal legislator?	please write yes or no
If yes, how many times?
*Have you ever attended PPW?	please write yes or no
If yes, how many times?
*Have you ever attended PADA's Dietetics Day at the Capital?	please write yes or no
If yes, how many times?
Are you a member of any ADA DPGs? If so, please list:
What do you hope to achieve in working as a Keystone Policy Partner?

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