December CrisisReady Registration Form

December -

Safeguarding Vital Documents

during Disasters

and

Narcan and Epi-Pen Autoinjector

Administration Training

Name*

First NameLast Name

Phone Number: If the CrisisReady event you have registered for is rescheduled at the last minute, we will call you to inform you of the change.

Please enter a valid phone number.

Email

example@example.com

At which location do you plan to attend the CrisisReady presentation?*

Greentown Century Villa Community Room on December 4th at 6:30pmKokomo-Howard County Public Library Main Branch, Meeting Rooms A & B, on December 11th at 5:30pmRussiaville Lions Club on December 17th at 6:30pm

Do you plan on attending the Narcan and Epi-Pen Autoinjector Administration first aid skills training following the presentation? The training will take approximately 20 minutes.*

YesNoI don't know

If you plan on bringing friends or family with you and they are not registering, please provide an estimate of how many people will attend with you.

We take pictures of our events for social media and for local and state reports of our activities. Please confirm that you consent to your picture, if taken, to be used in these reports and to posted to social media.*

Yes, any pictures I am may be used in the reports and posted to social media.No, any pictures that I am should not be used in the reports or posted to social media. (You will have to let us know during the event so we can avoid placing you in pictures. We do NOT accept responsibility for accidentally posting your picture if we are not informed at the event.)

Would you like to receive a monthly email reminder about upcoming CrisisReady events?

YesNo

CrisisReady Howard County