Your Name

First Name

Last Name

Name of Connections Attendee *

First Name

Last Name

Name of Direct Support Staff (if applicable)

Please Note: All direct support staff are required to attend in person for the full duration of our gathering in order to provide the best supportive environment possible.

First Name

Last Name

Phone of Direct Support Staff or Supervisor (if applicable)

(###)

###

####

Date Attending *

2nd & 4th Wednesdays 5:30PM - 7:00PM

MM

DD

YYYY