CT - West Haven: VA Blind Center - May 5 Event Registration

Date: Saturday, May 5, 2018
Location: Connecticut VA Hospital, 950 Campbell Ave, West Haven, CT 06516
Club: Yale Club of New Haven
Co-sponsor: Yale Veterans Association
Required fields are marked with an (*)

Personal Information

First Name: *
Middle Name:
Maiden Name:
Last Name: *
E-mail address: *
Birth Date: / /
Yale Affiliation: *
Yale Degree(s):

Daytime phone: *
Evening phone:
Mobile phone:
Home Address street: *
Street 2:
Street 3:
City: *
State / Province: *
Postal Code: *
Country: *
List registrant on the attendee list? *
  I am also willing to help the Day of Service organizers with support at this site on the Yale Day of Service. (If you checked this box, you will be hearing directly from the Day of Service leadership volunteers in your area regarding how you can help).
Please provide Alumni Records with my updated contact information as indicated above.

Guest Information

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Children under 18:

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Release and Indemnification Agreement

I have read, and I agree to, the conditions of this release and indemnification agreement.
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