Attendance Intentions for October 24, 2021

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* 1. Name of LeadingAge Wisconsin Member/Subscriber Organization

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

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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 click here to make your payment through our secure payment portal.

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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 24, 2021 (6:00 PM to 8:00 PM) at Stat's Brew Pub.

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 15, 2021 or until all reservations have been filled.

The cost to attend for each individual from a LeadingAge Wisconsin Provider Member/Subscriber 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. Please click here to make your donation through our secure payment portal.

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