#MedicalNutritionEquityNow Hill Day Registration Confirmation Please fill out this form once for EACH attendeed at the #MedicalNutritionEquityNow Hill Day. For children, use the voting address and email address of their parent/guardian.Attendees's Name* First Last Please confirm the following:* Yes, I plan to attend the #MedicalNutritionNow Hill Day No, my plans have changed and I am unable to attend Is the attendee a minor (under 18 years old)* No Yes Name of Parent or Accompanying Guardian* Attendee's Age* Attendee's Email Address* Attendee's Email Address (if applicable) Attendee's Cell Phone Number*Attendee's Cell Phone Number (if applicable)Attendee's Voting Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Attendee's Voting Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I will be staying at the following hotel* I will be arriving in time for the 3pm required training session at the Capitol Skyline Hotel on Monday, May 6* Yes No Please indicate when you will arrive* I will be leaving DC after 6:30pm on Tuesday, May 7* Yes No Please indicate when you will be leaving DC* I understand that by submitting this form I am cancelling my registration for the #MedicalNutritionEquityNow Hill Day* Yes If you registered for others and need to cancel their registrations as well, please enter their names below.I understand that the Patients & Providers for Medical Nutrition Equity Coalition will be booking all of my meetings on Tuesday, May 7 and I should attend only my assigned meetings.* I agree Please include any additional comments including whether the attendee is a child, and/or has accessibility requirements. Δ
