ASA Advocate Survey
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ASA Advocate Survey

If you would like join our active network of patients, doctors, attorneys, and supporters, please take a few minutes to fill out this survey on our members' interests. This will help us get you plugged in to the movement for safe access right away.

Personal Information:
* First Name
* Last Name
Organization
Title/Position
Contact Information:
* E-mail
* Mailing Address
* City
State
* Zip
* Phone Number
Fax Number
Web Page
Other Information:
Congressional District
(if you do not know go to www.house.gov and punch in your zip code)
Are you registered to Vote?
Are you a medical marijuana patient?
If so, what conditions do you use marijuana to treat?
Have you had a law enforcement interaction regarding medical marijuana?
Are you a physician?
Are you an attorney?
What groups outside of the medical cannabis community do you belong to (i.e. social clubs, political groups, or condition-based organizations)?
Which Activities Would You Like To Join ASA In?
Attending protests
Attending activist meetings and organizing political activity
Nonviolent civil disobedience protests
Calling or writing my representatives about legislation
Write a letter to the editor
Organizing in my electoral precinct
Attending constituents' meetings with my representatives
Hosting a house party
Comments
First Name
* Required Field
Americans for Safe Access • 510.251.1856 or toll-free 888.929.4367 • info@safeaccessnow.org • site map
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