Christine Stapell Legislative Day Stipend Application Form (*)First Name: Please enter your first name. Middle Initial: (*) Last Name: Please enter your last name. (*) AND Number: Please enter your ADA member number. (*) Address Line 1: Please enter your address. Address Line 2: (*) City: Please enter the city. (*)State: must contain only A-Z characters (*)Zip Code: Please enter your Zip code. +4: (*) Email: Please enter a valid e-mail address. (*)Telephone: Please enter a contact number. (*)I am applying for the following stipend: Christine Stapell Legislative Day Stipend (*) Event Start Date:Please select an event start date. (*) Event End Date:Please select an event end date. (*) Cost to attend; include proposed expenses:Please enter a numeric amount. Have you ever attended this event before?YesNoInvalid Input (*) Why is public policy important to the future of dietetics?Please answer this question. (*) List at least three (3) objectives for participating in this experience:Please explain. (*) Explain how this opportunity with our legislators and public policy will enhance your dietetic career: Please explain. (*) AND member since (year): Please enter the year. (year) (*) Number of years lived in Florida: Please select. (*) Member of FAND since (year): Please enter value. (year) (*) Member of District: 1-Broward2-Orlando3-Gainesville4-First Coast5-Miami6-Tampa7-Tallahassee8-Pinellas9-Palm Beach10-West Florida11-Panhandle12-Cypress13-Manasota14-Southwest FL15-Space Coast16-VolusiaPlease select your member district.(*)Since: Please enter a year. (year) Submit Application