Forming Our Future's Blueprint

 

Forming our Future’s Blueprint

Saturday, August 6, 2011

The Statehouse Inn

101 East Adams Street Springfield, IL 62701

Teen Summit Registration Form

Thank you for your interest in participating in Forming Our Future’s Blueprint 2011.  This summit was organized by BASUAH Ambassadors with you in mind. Please complete the registration form so that appropriate arrangements can be made to ensure a successful event.

Name
Address, City, State, Zip Code
Phone Number
E-Mail Address
Age
Gender
Food Restrictions (if any)

Arrive at the Statehouse Inn by 9:45 am to check-in!

Return the form by any of these methods:

1)     Fax completed form to (217) 558-7181

2)     Email completed form to bernice.fokum@illinois.gov

3)     Drop completed form off at:

Illinois Department of Public Health

535 West Jefferson Street, 5^th Floor

Springfield, Illinois 62761

(Black Glass Buildings across from McDonalds)