Attendance Intentions for October 27, 2019

Question Title

* 1. Name of LeadingAge Wisconsin Member Organization

Question Title

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

Question Title

* 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!

Question Title

* 4. Mailing Address

Question Title

* 5. City

Question Title

* 6. State

Question Title

* 7. Zip Code

Question Title

* 8. E-mail Address for Contact Person

Question Title

* 9. Please list the full name for each individual from your organization who will be participating in the Wisconsin Night Out on Sunday, October 27, 2019 (5:00 PM to 9:00 PM) at Sign Of The Whale.

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 9, 2019 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!

T