Information and Education Days 2023 Registration Form March 14, 2023March 14, 2023 Luis Macias This form is for the Information and Education Days 2023. Contact Lindsay.cunningham@heart.org with any questions. "*" indicates required fields Name * Required First Last Please provide your pronouns.Note: pronouns will be printed on your name badge. Voting Address * RequiredThis will be used used to match you with your state Assembly Member and Senator. In most cases, this will be your home address. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email * Required Cell Phone: * RequiredThis will be used in a text group with those participating in the same legislative meetings.What is your Tobacco Control Project or Affiliation? * Required CTCP-funded Project Coalition Member Contractor or Consultant Voluntary Health Organization Please spell out the Organization Name * Required Please spell out the Organization Name * Required Please spell out the Organization Name * Required Please spell out the Organization Name * Required Consent * Required By registering, I agree to attend legislative meetings with my Assembly member and my Senator. * RequiredEach legislative meeting requires a Meeting Lead. I agree to serve as the Meeting Lead for my Legislative Meetings? * Required Yes Only if Necessary No Have you developed a relationship with a current state Assembly Member, Senator, or their staff? If so, please indicate which member and your relationship. Legislative Caucus Meetings: Determining speakers and participants at Caucus meetings is being managed by the caucus leads and space is very limited. With I&E Day being held in-person, only 5-7 people can be present in the Caucus meetings. Please contact a caucus lead for more information. Black: Y’Lonn Burris yburris@amplify.love Latino: Rosendo Iniguez riniguez@healthcollaborative.org API: Priya Raman praman@appealforhealth.org LGBTQ+: Astin Williams awilliams@health-access.org Rural: Amber Morris AMorris@healthcollaborative.org Environment: Efraim Lopez efraim.lopez@sierraclub.org Native American Affairs select committee: Ravena Soto ravena.soto@etr.org Women’s: Kim Homer Vagadori kim@cyanonline.org Do you have any accommodations requests (e.g. visual or hearing impairment, accessibility needs, language interpretation, etc.). If yes, please detail those needs, and a staff member will be in touch to discuss further.Do you plan to attend the Monday, May 8 Opening Session? Attendance is strongly recommended, but not required. * Required Yes No On Tuesday, May 9, a box lunch will be provided for attendees. Please select which type of lunch you would like: * Required Gluten Free Vegan Vegetarian No dietary restrictions Photos and/or videos may be taken and included on the Tobacco Endgame Center’s website or used for promotional purposes. Do you agree to allow your image to be captured and used? * Required Yes No Would you like to be added to the Center’s email list? * Required Yes No Hotel Information Holiday Inn Sacramento Downtown – Arena 300 J Street, Sacramento, CA 95814 Hotel Website Check-in: May 8 Checkout: May 9 The opening night session and morning gathering session will be held in the hotel’s meeting space. The hotel is a 15-minute drive from Sacramento International Airport (SMF) and 14 min walk from the California State Capitol. Price: $95 (state rate) a night when you use the room block. We strongly encourage those staying overnight to book within the room block. Book RoomBefore completing your registration, please note that if your funding does not begin until at least May 1, 2023 (including Competitive Grants 22-10399 and 22-10403) then you cannot book travel or incur costs for travel (e.g. airfare, car rentals) prior to the full execution of your contract and be reimbursed by CTCP. Please contact your CTCP Program Consultant and Procurement Manager with questions.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on LinkedIn (Opens in new window)