Event Registration Form

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1. Name (Required.)

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2. Email (Required.)

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3. Phone (optional)

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4. Job title (Required.)

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5. Are you a member? (Please select all that apply.) (Required.)

I am a member of Black Men On The Hill

I am a member of Senate Black Legislative Staff Caucus

I would like to learn more information about these staff organizations

I am a member of both organizations

Event Registration Form

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1. Name (Required.)

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2. Email (Required.)

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3. Phone (optional)

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4. Job title (Required.)

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5. Are you a member? (Please select all that apply.) (Required.)

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6. Please provide a question you may have for senior staffers
(questions will remain anonymous) (Required.)

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7. Who do you work for? (Required.)

Event Registration Form

Question Title

* 1. Name (Required.)

Question Title

* 2. Email (Required.)

Question Title

* 3. Phone (optional)

Question Title

* 4. Job title (Required.)

Question Title

* 5. Are you a member? (Please select all that apply.) (Required.)

Question Title

* 6. Please provide a question you may have for senior staffers(questions will remain anonymous) (Required.)

Question Title

* 7. Who do you work for? (Required.)

1. Name (Required.)

2. Email (Required.)

3. Phone (optional)

4. Job title (Required.)

5. Are you a member? (Please select all that apply.) (Required.)

6. Please provide a question you may have for senior staffers
(questions will remain anonymous) (Required.)

7. Who do you work for? (Required.)