Town Meeting Registration Form

9/5/2008

Town Meeting Home

Sponsors and Community Partners

Printable Flyers (PDF):
  8.5 x 11"
  8.5 x 11" (Spanish)
  11 x 17"

Registration Form
Please fill out the following form to reserve your spot at the meeting. We will be accepting advance registrations online (or by telephone to 323-442-1096) until 4:00 p.m. on February 23. Advance registration will guarantee dinner on Friday and lunch on Saturday. You can also register at the door on the days of the event, but we cannot guarantee meals. Registration is free. Each registrant will receive a name badge and an agenda. Dinner will be served on Friday night, and snacks and lunch will be provided on Saturday. If you have any questions, or need to unregister, please send an e-mail to scehsc@usc.edu. (* denotes required field)
Name: Title: Organization: Address (Line 1): Address (Line 2): City: State: ZIP Code: Telephone Number: Email: Your Organization's Web site: Name on Conference Badge: Organization on Conference Badge: Days You Can Attend: Both Friday Saturday Childcare Needed? No Yes If yes, how many children? Spanish Interpretation Requested? No Yes Comments or other special accommodations requested: Please indicate which workshop topic you are interested in attending (this is not binding): Ports/Ships Freeways/Busy Roads Rail/Intermodal Distribution Centers Scientific Research Agendas Hazardous Materials One of the objectives of this conference is to help create a regional communications network for environmental health-related information. Please click "Yes" below if you agree to sharing your contact information with others for the creation of the network. No Yes If you selected "Yes" above, please notify us of any parts of your contact information that you do not* want to share: