Wisconsin Night Out in Philadelphia

Attendance Intentions for October 28, 2018

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* 1. Name of LeadingAge Wisconsin Member Organization

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* 2. The above listed organization is (please check one)

A LeadingAge Wisconsin Provider Member (the fee to attend this event is covered by the event sponsors)

A LeadingAge Wisconsin Associate Member (suggested donation for attending this event is $75 per person)

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* 3. If your organization is a LeadingAge Wisconsin Associate (business) Member, please enter the amount of your total donation (suggested at $75/person). You may make checks payable to LeadingAge Wisconsin, 204 South Hamilton Street, Madison, WI 53703; or call 608-255-7060 to pay by credit card. Thank you!

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* 4. Mailing Address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. E-mail Address for Contact Person

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* 9. Please list the full name for each individual from your organization who will be participating in the Wisconsin Night Out on Sunday, October 28, 2018 (4:30PM to 8:00 PM) at Tradesman's.

Participant 1

Participant 2

Participant 3

Participant 4

Participant 5

Participant 6

Because of the nature of this event and the cost for each person to attend, we must ask for your firm commitment to participate. We will accept reservations through the end of the day on Wednesday, October 10, 2018 or until all reservations have been filled.

The cost to attend for each individual from a LeadingAge Wisconsin Provider Member is covered by the event sponsors. Individuals from a LeadingAge Wisconsin Associate Member organization are invited to attend for a suggested donation of $75 per person. You may make checks payable to LeadingAge Wisconsin, 204 South Hamilton Street, Madison, WI 53703; or call 608-255-7060 to pay by credit card. Thank you!