REGIONAL MEETING REGISTRATION FORM

Please complete all sections of this form.

Personal

Ms. Mr. 

First Name:

Last Name:

Organization:

Title:

Work Address:

City:       State:

Zip Code:      County:

Work Telephone:

Cell or Home Phone:

Fax Number:

E-mail: 
 

attending

Please select which meeting you will be attending.

Greenbo State Park, March 14, 1 - 4pm
Maysville, May 24, 4 - 7 pm
Louisville, September 13, 6 - 9 pm
Lexington, June 23, 4 - 7 pm
Richmond, October 18, 5 - 8 pm
Hazard, September 28, 1 - 4 pm
Owensboro, TBA
Prestonsburg, September 6, 1 - 4 pm
Bowling Green, May 18, 1 - 4 pm
Somerset, September 19, 1 - 4 pm
Murray, October 17, 4 - 7pm

Professional

Organization

Education

Teacher
Counselor
Administrator
Professor
Principal
Other
     Describe :
   

Government

Local
State
Federal

Legal

Courts
Legislator

NPO

Mgt./Adm.
Services

Media

Editor
Reporter
Other
     Describe:

Other
     Describe:

 

Years in Profession

0-2
3-5
6-9
10-15
15+

 

Education
Select all that apply

High School
Bachelors
Masters
Ph.D.
JD
MD

Please list any credentials or licenses you hold.

 

VOLUNTEER EXPERIENCE

School
PTA
Civic Education
Community Organization
Youth Group
Hospital
Religious Group
Service Learning
Other
     Describe:

In a non-professional capacity, how many hours a week do you spend with civic organizations?

0-2
3-5
6-9
10-15
15+