Have Your Say Day 2013

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* 1. Your Contact Infomation

Name: *

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 2. To help us plan please let us know your anticipated travel arrangements

Driving (Carpooling)

Bus

Meet at the Capitol

Other (please specify)

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* 3. Have you met with your State Senator or Representative?

Never met either

Briefly. They may know me

Often. My State Senator will know me.

Often. My Representative will know me.

Often. My State Senator and Representative will know me.

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* 4. Please share any special relationship you have with the Same Students| Same Funding efforts?

I am parent.

I am a grandparent

I am a guardian

I am knowledgeable and support education reform

I am a Charter School Operator

I am an educator.

Prefer not to disclose.

Other (please specify)

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* 5. Do you need any special accommodations to participate?

I need wheel chair access.

I need frequent breaks.

I need access to power outlets for medical equipment.

I require an American Sign Language interpreter.

I require a Spanish Language Translator

Other (please specify)

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* 6. How did you find out about Have Your Say Day?

INCS eNewsletter (News & Events)

INCS Staff Member

INCS Board Member or Volunteer

School Liaison/ Teacher

An Education Reform Group (i.e., Stand For Children, DFER etc.)

Other (please specify)

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* 1. Your Contact Infomation

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* 2. To help us plan please let us know your anticipated travel arrangements

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* 3. Have you met with your State Senator or Representative?

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* 4. Please share any special relationship you have with the Same Students| Same Funding efforts?

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* 5. Do you need any special accommodations to participate?

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* 6. How did you find out about Have Your Say Day?

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* 7. Is there any additional information you would like us to know?