Exit this survey 6th Women's Empowerment Conference Registration Question Title * 1. Tell us about yourself. Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 2. What do you hope to get from the conference? Living healthy eating Increasing personal wealth Information on starting my own business Writing a business plan Funding my own business Ideas for healthy living and exercising Networking Spiritual Guidance Breast Cancer Furthering your education Other (please specify) Question Title * 3. What is your age? Question Title * 4. Did you attend our 2017 Women's Empowerment Conference? yes no Question Title * 5. How did you hear about the conference? Newspaper Flyer Friend Social Media Television Radio Mailer Work Family Strong Foundation table at an event Question Title * 6. General Liability Release: Family Strong Foundation, sponsors, and venue are not responsible for personal nor property damage. All scheduled events are subject to change. Participants’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize myself to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). yes no Question Title * 7. The conference is FREE; however donations will be solicited at the door. I understand that on the day of the conference donations will be solicited at the door. The donation is to offset the cost of the conference and cover lunch and conference materials but is not mandatory. Donations will be accepted in the following forms:cash, check, money order or credit card (please make checks payable to Family Strong Foundation). yes no Submit