Iowa Heart on the Hill - February 29, 2012 Survey

Wednesday, February 29, 2012
Historical Society and Iowa State Capitol Building
730 South 225th St.
Des Moines, IA

Join other advocates to speak with Iowa legislators in a strong, unified voice about the importance of fighting heart disease and stroke.

Join us for breakfast, a morning of trainings and legislative briefings and then put your skills to the test when you meet with your state legislators.

No cost to attend but advance registration is required.

*
1. Contact Information:

Contact Information: Name:
Company:
Home Address:
City/Town:
State:
ZIP:
Email Address:
Cell Phone Number:

*
2. Are you a Survivor (heart/stroke) and/or a Caregiver?

Are you a Survivor (heart/stroke) and/or a Caregiver?

*
3. Disability Needs: If yes, please explain:

Disability Needs: If yes, please explain:

*
4. Do you have any dietary restrictions? (Vegetarian) Food allergies? Please explain:

Do you have any dietary restrictions? (Vegetarian) Food allergies? Please explain:

Thank you for registering for the Iowa Heart on the Hill! Confirmation will be sent out via email. Please contact Christy Dreiling at 913-652-1972 or christy.dreiling@heart.org for more information or if you have any questions. Thank you.

Iowa Heart on the Hill - February 29, 2012Exit this survey

*1. Contact Information:

*2. Are you a Survivor (heart/stroke) and/or a Caregiver?

*3. Disability Needs: If yes, please explain:

*4. Do you have any dietary restrictions? (Vegetarian) Food allergies? Please explain:

Iowa Heart on the Hill - February 29, 2012
Exit this survey

*
1. Contact Information:

*
2. Are you a Survivor (heart/stroke) and/or a Caregiver?

*
3. Disability Needs: If yes, please explain:

*
4. Do you have any dietary restrictions? (Vegetarian) Food allergies? Please explain: