Required field: *

Advocacy Day: Wednesday, April 2, 2008
Registration Deadline is Wednesday, March 26, 2008
First Name:*
Last Name:*
Home Address:*
City:*
State:*
ZIP:*
Cell Phone:*
E-mail:*
Affiliation/Organization/School:*
Emergency Contact:*
Relationship:*
Primary Phone:*
Secondary Phone:

Meal Preference*
 
No Special Needs:
Vegetarian:
Vegan:
Other:

 
Explain any special needs (oxygen, wheelchair, hearing or visually impaired, etc.):


Advocacy Day Information:

This event will be taking place on Wednesday, April 2nd. Please arrive at the Respiratory Health Association of Metropolitan Chicago, located at 1440 W. Washington Blvd., at 5:45 AM. The buses' anticipated return to Chicago will be 6:00 PM.

I plan on taking the provided buses.*
I plan on meeting the group in Springfield (Travel costs not covered).*

 

RELEASES:

I understand that Advocacy Day is an all-day event that includes transportation to and from Springfield, IL on April 2, 2008. I hereby waive any and all claims against the Resporatory Health Association of Metropolitan Chicago (RHAMC) and its associates arising out this event. I understand that the RHAMC may be filming/photographing participants during their activities at Advocacy Day. I authorize the RHAMC to have and use photographs, slides, and videotapes of the person named in this application as may be needed for its public relations programs including brochures, nespapers, television, etc. I understand that participation in Advocacy Day requires that I participate in all of the day's events and conduct myself in an appropriate and professional manner. I will be responsible for any personal belongings and equipment that I bring with me to Advocacy Day; and the RHAMC is not responsible for their loss, misuse, or abuse. I understand that the use of tobacco, alcohol, or other drugs will not be tolerated, and if I use any of these during Advocacy Day, I will not be able ot attend another RHAMC sanctioned event. In the event of a medical emergency, I authorize RHAMC to transport me to a nearby medical facility.

Persons under the age 18 must obtain the consent of their parent or guardian in order to participate in the State Advocacy Days. Please fax the signed permssion slips to Jenny Li at (312) 243-3954.

Please confirm your age status:*
      18 years of age or over
      Under the age of 18
If under the age of 18, please download and fax the following consent form: Download Consent Form


Please confirm your agreement:*
    I Agree
    I Don't Agree