Every Person Counts! Engage, Educate, Empower . . . and Tell Us! Make sure we're counting your actions by filling out the form below! Not ? Click here. I am a: * Doctor Medical Student First Name: * Last Name: * Email: * ZIP: * Phone: I did these on the day/week of: INFORMAL EDUCATION: # of People Educated (total) Details (optional): PHYSICIAN / MED STUDENT PRESENTATION: # of Presentations # of People Educated (total) Details (optional): PUBLIC PRESENTATION: # of Presentations # of People Educated (total) Details (optional): FLIERS: # of People Educated (total) Details (optional): MEDIA: Date: Type:TV Radio Newspaper Story Op-Ed Letter to the Editor Blog Has it been published/Aired? Media Outlet Details (optional): DECLARATIONS: # of Signed Declarations Remember to input the names onto the map and hold onto the copies! Keep me updated on Doctors for America campaigns.
