Course Registration Form

Event Registration Form

Thursday, March 6th, 2025 from 6:00 until 8:00 PM. Doors will open at 5:30 PM for registration. Event will be held at Spoon River College Community Outreach Center: 2500 E. Jackson St. Macomb, IL 61455
Attendee Name*

First NameLast Name
Birth Date*

MonthDayYear
Attendee E-mail*
example@example.com
Pre-Event Survey

The following information is being collected for the purpose of compliance with the reporting requirements of the Healing Illinois Grant. The City of Macomb and the City of Macomb Police Department will utilize the information provided solely for grant-related reporting and evaluation purposes. All collected data will be maintained in accordance with applicable local, state, and federal laws governing data privacy and grant administration. The information will not be used for any purpose beyond the scope of the grant’s reporting obligations and will not be shared with unauthorized parties.
IN WHAT ILLINOIS COUNTY DO YOU CURRENTLY RESIDE?*
WHAT IS YOUR CURRENT ZIP CODE?*
Please enter the six digit zip code for your residential address (Ex: 61455)
WHICH RACE/ETHNICITY BEST DESCRIBES YOU?*
YesNo
HOW MANY HEALING ILLINOIS EVENTS HAVE YOU ATTENDED IN THE PAST?*
FacebookEmailNewspaperWeb ArticleRadioOther
WHAT IS YOUR PRIMARY REASON FOR ATTENDING THIS EVENT?*
Additional Comments
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Event Registration Form