NASW – CA “Political Action Posse”

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
County
Work Phone
Home Phone
Mobile Phone
E-mail
Educational and Employment Information
Professional Social Worker Designation (BSW, MSW, DSW, LCSW, etc.)

Employer1

Employment Title1

Employer2

Employment Title2

Are you a current student

Yes  No

If you are a student, which program?:

BSW, MSW,  DSW or PhD

Which University:

Are you a member of NASW?

Yes  No

Are you a(n) (check all that apply)

Adult Protective Services Social Worker
Adoption Social Worker
Child and Family Social Worker
Child Protective Services Social Worker
Correctional Social Worker
Geriatrics Social Worker
Government Employee
Medical Social Worker
Mental Health Social Worker
Occupational Social Worker
Private Practitioner
Retired
School Social Worker
Social Service Planner
Social Work Administrator
Social Work Supervisor
Social Work Faculty
Social Work/Welfare Researcher
Action Interests:
Are you willing to write a letter to your State Legislators, Governor or other State Agency?	Yes  No
Are you interested in participating in group political events sponsored by NASW-CA, labor groups, consumer groups, and other similar provider organizations in your area?	Yes  No

Are you interested in participating in group political events sponsored by NASW-CA, labor groups, consumer groups, and other similar provider organizations in Sacramento?

Yes  No

Are you interested in providing NASW-CA background material on your issue(s) of expertise when needed?

Yes  No

Are you interested in representing NASW-CA by testifying at a Legislative Hearing in Sacramento on your issue(s) of interest, upon request?	Yes  No
Are you willing to participate in meeting with Legislators or staff in the Legislative district you live in?	Yes  No

Issues of interest (Check all that apply):

Adult Protective Services

Aging issues, including long term care

Child Care/preschool

Child health & family health (including Healthy Families)

Child Welfare
Adoption
Child Protective Services
Family Reunification & Maintenance
Family Preservation
Foster youth emancipation
Group/residential Care
Independent Living
Kinship Care
Youth development
Foster Care

 

Criminal Justice & Corrections

Juvenile Justice
Gang violence, incl. race relations & police    brutality
Family Law
Child Custody
Child Support

 

Human Services Administration
Public Assistance
CalWORKs
Supplemental Security Income (SSI)
General Assistance
Food Stamps
In Home Supportive Services (IHSS)
Education (K-12)
School Social Work
Education (Higher)
Social Work Education

 

Healthcare Access
Healthcare services/programs including Medi-Cal

Nutrition and Obesity
Medical Social Work
Mental Health

Children
Adolescents
Adults
Older Adults
Substance Abuse (addictions, alcohol, tobacco, and other drugs)
Military and veterans issues
Developmental Disabilities
Disabled
Domestic Violence
Housing
Immigrants (legal, illegal, refugee, citizenship)
HIV/AIDS

Homeless, including hunger
Women's health (including reproductive health)

 

Civil Rights
Gender Issues
Hate Crimes
LGBT Issues
Community Organizing
Cultural Competency
Private Practice

 

Other (please describe)

THANKS FOR SUBMITTING YOUR FORM AND JOINING NASW-CA'S POLITICAL ACTION POSSE!  WE WILL BE IN TOUCH SOON!

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