ECIC | Star Power

May 21, 2008
REGISTRATION FORM

If you have problems using this form, please contact us at (517) 371-9000 or email info@ecic4kids.org.

Yes, I will join you for Star Power: Celebrating Our Rising Stars!

Prefix:

First Name:

M.I.:

Last Name:

Suffix:

Title:

Organization:

Address (line 1):

(line 2):

City:

State:

Zip:

Email:

Primary Phone:

Ph. Extension:

Cell Phone:

Primary Fax:

This is a catered event; please indicate if you would prefer a vegetarian option. Yes No

Please enter your State Senator and Representative. If you do not know who they are, please use this link to obtain this information: Senator & Representative Look-up Senator Representative

Are you are associated with a Great Start Collaborative? If so, please select it from this list:

Are there youth attendees in your party? If Yes, enter the number of youth attendees here:

If you have questions or need assistance with this form, please email info@ecic4kids.org