California United for Nursing Home Care

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Last name

E-mail address

City, State Zip

Choose the best way to describe your support for quality nursing home care:

	I'm a nursing home worker		I'm a resident's family member
	I'm a nursing home resident		I'm a nursing home provider/manager
	I'm an elected official		I'm a religious leader
	I'm an advocate for seniors		I'm a community leader
	Other/not listed