SRPMIC Earth Day Registration Form
Please fill out completely.
Last Name: _____________________________ First Name: _________________________
*** Must be 18 years old or older***
Phone number: _____________________
Email: _________________________________
Total number of attendees (including yourself): __________
Number of attendees 12 years old or younger: __________
Number of attendees with limited mobility: __________
Does anyone in your group have a cultural sensitivity? Yes ___ No ___
Special requests (while we cannot guarantee specific service projects, we will do our best to
accommodate your needs):