Pharmacy Day at the WV Capitol RSVP / Appointment Scheduler

Complete this RSVP form. We will help to coordinate appointment times with a team of pharmacists and students to meet with different legislators to discuss the importance of pharmacy access to patient care. Your addresses will be used to identify your legislators, and only your cell phone number and email address will be shared with your team members for purposes of communications on the day of the event.

Name *

First

Last

I am coming to the afterparty at Axes and Ales. *

• YES
• NO
• I am unsure currently and will RSVP to info@wvpharmacy.org if I am coming.

It is important to get proper head count so we can reserve enough space and food/drinks.

Email Address *

Email

Confirm Email

This will be the primary means of receiving updates about Legislative Day up to the day of the event.

Phone (Cell Preferred) *

In the instance quick communication is needed DURING Legislative Day

Please choose one: *

• Pharmacist
• Student (WVUSOP)
• Student (UCSOP)
• Student (MUSOP)
• Technician
• Faculty/Staff (WVUSOP)
• Faculty/Staff (UCSOP)
• Faculty/Staff (MUSOP)
• Other

Year in School *P1P2P3P4

Home Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

We ask this to try to pair you with legislators from your area.

School or Work Address (if a different area than home address)

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Do we have permission to share your cell phone number and email address with others on your small legislative team you will round with? This will allow us to communicate the morning of legislative day time/location changes, etc. *YesNo

Have you been to legislative day before? *YesNo

Would you be willing to be a team leader? This designation would just be responsible for a small group of people to communicate with while at the Capitol to ensure our small groups get where they need to be. *YesNo

Do you have a preference or relationship with any legislators? Any preference on meeting with legislators in your home or work/school region?

Comments/Questions/Concerns

Submit