Event Registration Form
Last Day to register: June 12, 2023
Communities in Action: Russell
Please see the event date, time and location below.
Attendance Information
ALL community coalition taskforce/groups are REQUIRED to have 3-5 coalition members attend the Communities in Action Workshop! Make sure you list each coalition member below- if you have questions please email communitysupport@ks.childcareaware.org.
Date
:
June 21, 2023
Time
:
9:00-4:00
Location: TBA
Attendee Information
Please fill name and contact information of for all attendees. Each person in your coalition needs to be registered here. All coalitons are required to have 3-5 members. Do NOT duplicated coalition members below!
Name of Child Care Coaliton
*
City/County
*
Your Name
*
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Number of community coalition members attending
*
Coalition Member Name
*
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Coalition Member Name
*
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Coalition Member Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Coalition Member Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please verify that you are human.
*
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