Registration for Day at the Capitol 2008 Survey

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1. I will be attending the 2009 Fight Back at the Capitol.

I will be attending the 2009 Fight Back at the Capitol. Yes

No

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2. Please provide your contact information:

Please provide your contact information: Name:
Organization:
Address (where you vote, no PO Box):
Address 2:
City/Town:
ZIP/Postal Code:

3. Mailing Address (if different, i.e PO Box).

Mailing Address (if different, i.e PO Box). Address:
Address 2:
City/Town:
State/Province:
ZIP/Postal Code:

4. Preferred Email Address:

Preferred Email Address:

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5. Preferred Phone:

Preferred Phone:

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6. Emergency Contact Information:

Emergency Contact Information: Name:
Phone:
Other Phone:
Relationship:

7. Are you a cancer survivor or a caregiver?

Are you a cancer survivor or a caregiver? Yes, I am a cancer survivor.

Yes, I am a caregiver.

8. If you feel comfortable answering, what type of cancer?

If you feel comfortable answering, what type of cancer?

9. State legislators you know personally or would like to meet with at Fight Back at the Capitol: (We will do our best to fulfill all requests.)

State legislators you know personally or would like to meet with at Fight Back at the Capitol: (We will do our best to fulfill all requests.)

10. Hotel room accommodations for March 5, 2008. Hotel is provided first come, first served based on volunteers who are traveling. Hotel information will be sent with confirmation packet.

Hotel room accommodations for March 5, 2008. Hotel is provided first come, first served based on volunteers who are traveling. Hotel information will be sent with confirmation packet. Yes, I will need a hotel room for January 26, 2009

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11. Transportation is provided from St. Cloud and Duluth. Vans will be provided for volunteers who are traveling.

Transportation is provided from St. Cloud and Duluth. Vans will be provided for volunteers who are traveling. I will travel on my own to the event.

I will be traveling from Rochester and would like transportation to the capitol.

I will be traveling from St. Cloud and would like to take the van with staff and volunteers.

I will be traveling from Duluth and would like to take the van with staff and volunteers.

Other (Please specify.)

12. Personal Accommodation Requests:

Personal Accommodation Requests: I need communication, interpreting, or alternative format for materials.

I need handicapped accessible accommodations.

I have dietary restrictions.

Other (please specify)

Registration for Day at the Capitol 2008

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