Bring The Vote Home New York Sign Up

Thank you for your interest!

Below is the registration form. Don't worry about having a solid BTVH plan yet, we will be in touch soon with information about how to roll this out to your patients! HCA will be holding a series of conference calls to talk with BTVH Champions (your agency's point person) about how to get going! We will also be here along the way for troubleshooting and assistance!

Question Title

* 1. Provide us with some information about you!

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Please identify the individual within your agency that will serve as the BTVHNY Champion or point person (if different from yourself).

Name

Email Address

Phone Number

Question Title

* 3. How many BTVHNY distribution packets would you like us to send? In other words, how many patients do you plan to distribute the materials to? (Ex: 100, 250, 500, etc.)