Senior Housing Now Rally Registration Form

We’re excited you are going to participate in the LeadingAge Senior Housing Now rally at the United States Capitol in Washington, DC on Wednesday, May 8, 2019 from 1:00 pm – 2:00 pm.

It is important that all participants register to join the rally. Please use this form to register as an individual attendee or a group leader. After you've registered, we will send out updated information directly to you about the rally. In the meantime, please visit the Senior Housing Now website for campaign details and other resources.

1. Contact Information *This question is required.

	Primary contact first name
	Primary contact last name
	Primary contact email
	Primary contact cell phone #
	Name of the Community
	Community Address
	Community City
	Community ZIP Code

2. Community State *This question is required.

4. If yes, who will you visit? *This question is required.

5. Participants *This question is required.

	Number of Participants
	Will your participants arrive by bus?
	If yes, how many buses?

5. List the names of individuals in your group who are participating in the rally

Space Cell	First Name	Last Name	Email address	Phone Number
1	First Name	Last Name	Email address	Phone Number
2	First Name	Last Name	Email address	Phone Number
3	First Name	Last Name	Email address	Phone Number
4	First Name	Last Name	Email address	Phone Number
5	First Name	Last Name	Email address	Phone Number
6	First Name	Last Name	Email address	Phone Number
7	First Name	Last Name	Email address	Phone Number
8	First Name	Last Name	Email address	Phone Number
9	First Name	Last Name	Email address	Phone Number
10	First Name	Last Name	Email address	Phone Number
11	First Name	Last Name	Email address	Phone Number
12	First Name	Last Name	Email address	Phone Number
13	First Name	Last Name	Email address	Phone Number
14	First Name	Last Name	Email address	Phone Number
15	First Name	Last Name	Email address	Phone Number
16	First Name	Last Name	Email address	Phone Number
17	First Name	Last Name	Email address	Phone Number
18	First Name	Last Name	Email address	Phone Number
19	First Name	Last Name	Email address	Phone Number
20	First Name	Last Name	Email address	Phone Number