Tuesday, May 19, 2009

EMP. DAY REGISTRATION FORM - Google Docs

 

ONE FORM PER PERSON

4TH ANNUAL EMPOWERMENT DAY

Thursday, June 11, 2009

leaders In our Lives”

Sponsored by Detroit-Wayne County Community Mental Health Agency

Located at:

Burton Manor

27777 Schoolcraft Road
(I-96, just west of Inkster Road)

Livonia, Michigan

8:00am-3:00pm

REGISTRATION FORM

Name: ______________________________________________________________

Address: ____________________________________________________________

City: _______________________________________________________________

Contact Phone:_______________________________________________________

Organization/Clubhouse_____________________________________________

Full breakfast and light lunch will be served. Please circle one:

Diabetic Vegetarian Regular

Fax registration forms to: 313 833-4280 OR e-mail to: aaltman@co.wayne.mi.us

Questions? Contact Anna (313) 833-7440 or Jamar (313) 833-9860

FORMS MUST BE RECEIVED NO LATER THAN JUNE 1

EMP. DAY REGISTRATION FORM - Google Docs

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