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SHARE YOUR SUCCESS STORY
Sharing your story can make the difference! Please fill out the information below. IMCHC/Covering Kids and Families Illinois representative will follow-up with you within a week. CONTACT INFORMATION
*Name:
City*
Email
Home Phone
Work Phone
ext.
Cell Phone
At least one phone number is needed. If you do not have a phone, please provide an alternative contact name and phone number where we may reach you at.
Alternative Contact Name:
Alternative Phone:
YOUR STORY Who in your family has coverage through All Kids or FamilyCare? (Please list each member separated by a comma.) How long have you/they been covered through All Kids or FamilyCare? months years
Were you/they uninsured prior to obtaining coverage through All Kids or FamilyCare? yes no Does anyone in your family have specific medical problems, minor or serious? yes no If yes, please specify illnesses
DEMOGRAPHICS Your age
Household Size (including yourself) 1 2 3 4 5 5 6 7 8 8+
Approximate annual household income size <20,000 20,001 - 39,999 40,000 - 79,000 >80,000
Race/Ethnicity White/Caucasian Asian/Pacific Islander Hispanic/Latino Black/African American Native American Other
PRESS & EVENTS Are you willing to share your story with the media or at an event? yes no
If you have any questions, please call Laura Leon at 312-491-8161 or you can email her at lleon@ilmaternal.org. Thank you for your time!
