"Health Care Proxy & Living Will" workshops
Registration Form. Event: Indians Americans of Burlington
Attendee 1: Name
*
First Name
Last Name
E-mail ID
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
You may register up to 4 participants with this submission:
Attendee 2
First Name
Last Name
Attendee 2 email
example@example.com
Attendee 3
First Name
Last Name
Attendee 3 Email
example@example.com
Attendee 4
First Name
Last Name
Attendee 4 Email
example@example.com
Do you know what is Health Care Proxy & Living Will and why it is important?
Yes
No
Other
Have you prepared and is your executed "Health Care Proxy" document readily available?
Yes
No
Other
Your relationship with ICC is (select as many as applicable):
Client
Donor
Volunteer
Member
Leader of supporting/partner organization
Other
How did you learn about the workshop?
IAB invite / Newsletter
ICC announcement / invitation
ICC Website (http://www.ouricc.org)
Facebook / social media
Information forwarded by a friend
Other
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