Please complete by January 10th.
DO Day in Olympia
Wednesday, January 10, 2020
9am-3pm

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Credientials (DO, MD, OMSI, II, III or IV) Students please identify school below

Question Title

* 4. Medical School Name 

Question Title

* 5. Year of Medical School (OMS I, OMS II, etc. or Alumni grad year, N/A if doesn't apply)

 
If you are a registered voter in Washington State, please provide your registered voter address. This will allow us to identify your legislators for appointment setting.

Question Title

* 6. Street Address

Question Title

* 7. City

Question Title

* 8. Zip Code

Question Title

* 9. Cell Phone Number

Question Title

* 10. Email

Dietary Restrictions & Transportation

Question Title

* 11. Dietary Restrictions (N/A if does not apply)

Question Title

* 12. If you are coming from the Yakima area, indicate below if you wish to ride the bus:

T