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Cafe' Conversation RSVP

 

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1. First Name

First Name

*

2. Last Name

Last Name

3. Address

Address

*

4. City

City

5. State

State

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6. Zip Code

Zip Code

7. Email Address

Email Address

8. Phone number

Phone number

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9. Are you an RSC consumer?

Are you an RSC consumer?   Yes No Family Member is Consumer Friend is Consumer

10. Organization Affiliation (if any)

Organization Affiliation (if any)

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11. Event Site You Will Attend

Event Site You Will Attend   Cleveland - March 1 at Cleveland Center for Families and Children Columbus - March 2 at Main Library Toledo - March 3 at Dana Conference Center Cincinnati - March 4 at College Hill Recreation Center Marietta - March 10 at Washington State Community College Youngstown - March 11 at Butler Institute of American Art, Butler North Education Center Dayton - March 12 at Wright State University Student Union Dover - March 15 at Tuscarawas Co. Senior Center Lima - March 16 at Veterans Memorial Civic & Convention Center Akron - March 18 at Helen Arnold Community Learning Center Athens - March 29 at Ohio University, Baker University Center Portsmouth - March 31 at Southern Ohio Medical Center, Friends Center

12. Do you need any special accommodations?
(Please let us know if you have a hearing impairment so that we can have a sufficient number of interpreters for small group discussion.)

Do you need any special accommodations? (Please let us know if you have a hearing impairment so that we can have a sufficient number of interpreters for small group discussion.)

13. Will you bring a guest?

Will you bring a guest?

14. If bringing a guest/guests, please indicate how many?

If bringing a guest/guests, please indicate how many?

15. How did you hear about Cafe' Conversations?

How did you hear about Cafe' Conversations?   From a Friend From a VR Counselor Saw it Online Received a Postcard Invite Received an Email Saw a Poster Other

Other (please specify)