JDRF Research : Juvenile Diabetes Research Foundation in Australia

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Promise to Remember Me

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Campaign Tool Kit

Tell Us About Your Meeting

Campaign Events

Promise to Remember Me

Tell Us About Your Meeting

Please note: All fields are required.
If you do not have the information for a particular field, please enter "N/A" or "none".

1. Contact information from person submitting picture:
*First Name:**
*Last Name:**
*Address:**
*Suburb:**
*State:**
*Postcode:**
Home Phone:	( )
Work Phone:	( )
*Email:**
2. Add an Attendee Please enter the names and email addresses you have for all meeting attendees below.
*First Name:**
*Last Name:**
Email (Optional):

Add Another Attendee Remove Attendee
3. Name of MP or Senator whom you met
Name: Electorate:
4. Date of meeting
(MM/DD/YYYY)
5. Place/City of meeting

6. Does the MP or Senator support increased funding for Diabetes Research?
Yes No
7. Did any other legislative or diabetes issues come up in your conversation?
Yes No If yes, please elaborate: (Maximum characters: 2000) You have characters left.
8. Did the Member request any information or is there any need for JDRF staff to followup with his/her office?
Yes No If yes, please elaborate: (Maximum characters: 2000) You have characters left.
9. Does the Member have a personal connection to diabetes?
Yes No If yes, please elaborate: (Maximum characters: 2000) You have characters left.
10. Does anyone who attended the meeting have a personal relationship with the Member?
Yes No If yes, please elaborate: (Maximum characters: 2000) You have characters left.
11. Summary/Comments of the meeting
Please provide a summary of what happened at your meeting or any further comments (Maximum characters: 2000) You have characters left.
12. Submit Picture For those submitting a picture, please list names from left to right, front row to back row, and include a list of those who attended but were not included in the picture, if applicable.
Image 1: Image 2: Image 3:
Please click the submit button once. If uploading an image, allow some time for the image to upload.