CP Awareness Day 2011

In Honor of Cerebral Palsy Awareness Day:

CDC's National Center on Birth Defects and Developmental Disabilities & Reaching for the Stars. A Foundation of Hope for Children with Cerebral Palsy
invite you to a special presention

Thursday Evening, March 3, 2011, 6:30-8:30
Doors open at 5:30 for John Quinn's book signing and refreshments.
Tom Harkin Global Communication Center
1600 Clifton Rd. NE, Atlanta, GA 30333

Special guest speakers Michael Kutcher and John Quinn

This event is free and open to the public.

Registration is required. (Registration is now closed for non-US citizens).Please complete the form below.

Question Title

* 1. Contact information:
(All fields require an answer to process registration)

First Name: *

Last Name:

Representing (if not applicable please put "n/a")

Address:

City:

State:

ZIP/Postal Code:

Email Address:

Re-enter Email Address: *

Phone Number: *

Question Title

* 2. What is your role? (Parent, Provider, Etc.?)

Question Title

* 3. Would you like to register additional family members or guests? If so, please ensure that all are aware of the need to contact CDC immediately if they are not U.S. Citizens as additional processing time is needed. If you have more than five guests, extra space is available at the end of this form.

Guest 1:

Guest 2:

Guest 3:

Guest 4:

Guest 5:

Question Title

* 4. Are you a US Citizen?
Registration is now closed for non-US citizens. Sorry for any inconvenience. For questions contact Julia Richardson at Jrichardson1@cdc.gov or 404-498-4054.

Yes, I am a U.S. Citizen.

No, I am not a U.S. Citizen.

Question Title

* 5. Will you need special accommodations?

Yes

If yes, please specify:

Question Title

* 6. How did you hear about this event?

E-mail

CDC Web site

Other Web site

Direct mail brochure

Word-of-mouth

Other

Other (please specify)

Question Title

* 7. Please use this space (if needed) to register additional family members. Please provide each guest's full name.

• Some of the fields in this registration form require an answer and registration will not be processed if these fields are left blank. For instance, the email field must be filled out. This is our primary method to reach you with important information about the event so this information is required to register.

• Registration confirmations/ reminders will be sent via email on Feb 24th. This email will contain important information regarding your visit to CDC. If you do not receive an email with this information by Feb 24th, please contact Julia Richardson. If you registered guests, you’ll need to share this confirmation information with them.

• Please write down the contact information for Julia Richardson (Jrichardson1@cdc.gov, 404-498-4054). If you have any question/concerns, you’ll need to contact her and once you have completed the registration form you will no longer have access to her contact information.

Question Title

* 1. Contact information:(All fields require an answer to process registration)

Question Title

* 2. What is your role? (Parent, Provider, Etc.?)

Question Title

Question Title

* 4. Are you a US Citizen?Registration is now closed for non-US citizens. Sorry for any inconvenience. For questions contact Julia Richardson at Jrichardson1@cdc.gov or 404-498-4054.

Question Title

* 5. Will you need special accommodations?

Question Title

* 6. How did you hear about this event?

Question Title

* 7. Please use this space (if needed) to register additional family members. Please provide each guest's full name.

* 1. Contact information:
(All fields require an answer to process registration)

* 4. Are you a US Citizen?
Registration is now closed for non-US citizens. Sorry for any inconvenience. For questions contact Julia Richardson at Jrichardson1@cdc.gov or 404-498-4054.