Register for WCSAP Lobby Day: February 15, 2012

1. Registration and Planning for Lobby Day February 15, 2012

Please provide the following information to register for Lobby Day 2012. Registration for Lobby Day will close on February 10, 2012:

1. Member Program Name:

Member Program Name:

2. Name of Attendee (please fill out survey for every member attending):

Name of Attendee (please fill out survey for every member attending):

3. Mailing Address:

Mailing Address:

4. City:

City:

5. Zipcode:

Zipcode:

6. Telephone:

Telephone:

7. Email:

Email: