4th Annual Faith Based Conference on HIV/AIDS and Substance Abuse Online Registration Form

Friday - June 1, 2007 • 8:30 a.m. - 4:00 p.m.

Mount Calvary Baptist Church

1257-59 W. 111th Street • Chicago, Illinois

Please complete the form below to register for the conference on June 1, 2007 and your name will be added to the guest list.

Enter today's date : -- mm/dd/yy

Please provide the following contact information:

Name
Title
Organization
Address1
Address2
City_State_Zip
Work Phone
FAX
E-mail
URL

Select any of the following options that apply:

Church/Faith Based           501(c) 3 Non-Profit          Private Company/Corporation  Governmental Agency        
Health Department            Individual                   Other

Any Additional Comments ... ?


Daryl Edwards, Webmaster.
Copyright © 2007 [Prevention Partnership, Inc]. All rights reserved.
Revised: April 27, 2007