Take 5: We're All in This Together - Event Registration

Register here for Take 5: We're All in This Together - An Ohio Youth Services Day of Dialogue at the Chillicothe and Ross County Public Library Main Library Annex, Friday, May 3 from 9:00 a.m. - 4:30 p.m. (doors open at 8:30). Please answer all questions below. Registration is not complete until you submit your form. If you need to keep a copy of your form for your records, please print or save before submitting.

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* 1. Registration information:

Name: *

Workplace/Affiliation:

Email Address: *

Phone Number:

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* 2. The event fee of $25 is payable by cash or check in advance or on site, and will cover your lunch, morning and afternoon refreshments, and materials. SERLS is graciously handling registration payments for this event. Please select your payment method.

Check, paid in advance to SERLS. You will receive a follow-up email with instructions for mailing your check.

Check, paid on site on Friday, May 3.

Cash, paid on site on Friday, May 3.

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* 3. 7 Miles Smokehouse will cater lunch. Vegetarian and gluten-free selections will be provided. A vegan alternative will be available. Do you have any dietary requirements?

No special requirements

Gluten free

Vegan

Vegetarian

Other (please describe)

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* 4. Take 5 attendees are encouraged to share their experiences and ideas in dialogue with others, but also through an attendee poster session. You may bring a representation of successful activities, services or programs offered at your organization. This might include a poster or tri-fold display, slideshow on a laptop, promotional materials, etc. Some inspiration from a previous Take 5 event.

Feel free to bring and share anything you feel others would enjoy. Please plan to arrive by 8:30 a.m. on May 3 to set up your display.

Are you interested in contributing a poster or other display?

Yes

Not sure yet; ask me later (event organizers will send a follow-up email if you select this option)

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* 5. Optional activities on Thursday afternoon/evening, May 2 will take place at local attractions and at the library annex. A dinner outing may be organized at one or more local restaurants. There will be opportunities to enrich and enhance your Take 5 experience, build your network, and have fun. Light snacks will be provided at the library annex.

A special group rate of $94 plus tax is available for overnight lodgings at the Christopher Inn and Suites hotel, about 1.5 miles from the library. The hotel has free hot breakfast, free wi-fi, and an indoor pool and spa. Call 1-740-774-6835 and ask to reserve a room under the "Take 5" block. Make your reservation by April 2 for this group rate.

Note: Answering Yes to the below questions does not oblige you to participate. This is to gauge interest for planning purposes, and to develop a contact list of interested attendees with whom to follow up. You do not have to stay overnight at the Christopher Inn to participate in Thursday activities.

	Yes	No
Are you interested in participating in Thursday activities?	Are you interested in participating in Thursday activities? Yes	Are you interested in participating in Thursday activities? No
Do you expect to stay overnight at Christopher Inn on Thursday?	Do you expect to stay overnight at Christopher Inn on Thursday? Yes	Do you expect to stay overnight at Christopher Inn on Thursday? No

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* 6. (optional) Questions or comments for the event organizers?

Please click the "Done" button below to complete your registration.