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Name
|
____________________________
|
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Address
|
____________________________
|
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City/State/Zip
|
____________________________
|
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Phone/Fax
|
____________________________
|
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Email
|
____________________________
|
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Group Name
|
____________________________
|
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What issues are you working on personally?
|
____________________________
____________________________
____________________________
____________________________
____________________________
|
|
What issues does your group work on?
|
____________________________
____________________________
____________________________
____________________________
|
|
Are you planning to stay both days or only one?
|
_______
Both ______ One |
|
Do you have any special needs?
|
____________________________
____________________________
____________________________
|
