Registration Form   

I want to personally tell Congress how important Medicaid is for people with mental retardation. I’ll be there!

 

Send form to Voice of the Retarded 5005 Newport Dr. #108, Rolling Meadows, IL 60008 

Fax: 847-253-6054  vor@compuserve.com   *   Phone: 847-253-6020  *  A non-profit 501(c)(3) organization

 

Name(s) __________________________________________________                                                         

Address                           ___________________________________________________                               

City, State, Zip              ________________________________________________________                      

Home Phone               __________________________________________________                                    

Work Phone          __________________________________________________                                          

Email                                                                _________________________________________________

Family/professional org/company (if applicable)             __________________                                                           

 

Charge card: � MC   � Visa    Expires

Credit card number                  _______________________________________                        

Signature                       ________________________                                 

 

Mark all that apply:

___$50 per person for member registration at the Annual Meeting on Saturday, June 10 if paid by May 31, 2006  <2006 WASH-REG>

 

___$60 per person for member registration after 5/31.            <2006 WASH-REG>

 

___$75 per person for non-member registration at the Annual Meeting on Saturday, June 10 includes one-year membership if paid by May 31, 2006.          <2006 WASH-REG>

 

___$85 per person for non-member registration after 5/31.  Membership included.         <2006 WASH-REG>

           

 ___A donation of     $_________is enclosed          <2006 WASH-DONA>

 

___ I/We will attend the Washington Initiative only