2022 Senior Active Adult Resource Extravaganza Village of Wheeling Senior Active Adult Resource Extravaganza Organization Registration Form Question Title * 1. What type of service do you offer? Assisted Living Memory Care Nursing or Rehabilitation Home Care Transportation Legal Other (please specify) OK Question Title * 2. Organization Information Contact Name Organization Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number OK Question Title * 3. What are you able to provide as a donation for participation? Raffle Prize valued at $25 Snack contribution i.e. cookies, fruit tray, candy, etc. OK Question Title * 4. Do you need any special accommodations for your display? Yes No What is it you need? OK Question Title * 5. Our organization agrees to participate in the Village of Wheeling Police and Human Services Departments Senior Active Adult Resource Extravaganza on October 6, 2022. Our organization will be set up and ready to go by 2:00 p.m. and stay through 4:00 p.m. We further agree that our representatives will not directly solicit attendees unless directly solicited by attendees. The Village of Wheeling reserves the rights to ask a participating organization and it's representatives to leave at anytime Village staff or designee determine the non-solicitation policy has been violated. Do you agree with these policies? Yes No OK Question Title * 6. Thank you for your interest in the The Senior Active Adult Resource Extravaganza. Your organization will receive additional correspondence from the Human Services Department as we get closer to the event. Should you have any questions, please comment in the box below or contact the Village of Wheeling Human Services Department at 847.459.2606 or email at dmurillo@wheelingil.gov. OK DONE