2019 Care Day Service Provider Registration Form

Primary Agency Contact *
Primary Agency Contact
Primary Contact Phone *
Primary Contact Phone
http://
Agency Address *
Agency Address
Public Contact
Public Contact
CONTACT PERSON FOR CLIENTS SEEKING YOUR ORGANIZATION'S SERVICES
Public Phone
Public Phone
PHONE NUMBER FOR CLIENTS SEEKING YOUR ORGANIZATION'S SERVICES
Emergency Responder Contact
Emergency Responder Contact
This info will not be published to the general public, but may be used by local emergency services, such as police, fire and chaplains, when responding to people in urgent need. NOTE: This is not asking for your personal emergency contact.
Emergency Response Number (Day)
Emergency Response Number (Day)
Emergency Response Number (Night)
Emergency Response Number (Night)
Category of Services *
Check all that apply:
Briefly describe what your organization does.
Please describe what you will provide to guests at Care Day, such as: Services, Goods, Information, Sign-ups for your programs.
If you feel you must have more than one table, please explain:
How many chairs will your staff need?
How many chairs will guests need (if any)
Electricity *
Do you need access to an electrical outlet
Internet Access *
Volunteer Help
If yes, please describe how many and what are they needed for?
Care Day Promotional Materials
We can provide postcards and/or flyers in English and Spanish (for your clients). These are also available for you to print, found at https://www.careday.net/media-promotion/
Networking Reception *
Would you like to attend a networking reception with other service providers prior to Care Day?
Who else should be at Care Day?