Palliative Care State Policymaker Summit Option 1 Form

Title

Your Phone Number

State

Describe your state’s progress on advancing its palliative care goals, including any challenges you have encountered.

Describe how attending this summit would advance this work.

Identify the two individuals (including titles and agencies) who will attend the summit on behalf of your state if selected. Please also note if your state would interested in sending a third attendee (self-pay) if space allows.