"Ways to Stretch Your Dollar During Tough Economic Times" Elder Conference Registration Form

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Conference Registration Form

Email *

First and Last Name *

Email Address: *

Address City, State, Zip Code *

Phone Number: *

Gender *

Male

Female

Prefer not to say

Other:

Do you have experience with the Black Impact Collaborative (BIC)? *

Had Yard Clean-Up Services

Had Snow Removal services

Attended a previous Elder Conference

Attended BIC's The Black Experience Event

Visited a BIC table at a Community Event

Visited our Website

Viewed "What's the 411" Facebook Podcast

N/A - Not Applicable

Required

Indicate the Events/Workshop you have participated in? *

Just for the "Health of It"

Prostate Cancer

Diabetes Workshop

Dumpster Days

Technology /Estate Planning Workshop

The Black Experience

Roll Bounce

Was a volunteer for a BIC event

N/A - Not Applicable

Required

What type of computer do you own (check all that apply)? *

Desktop

Laptop

Ipad

Tablet

None

Required

Do you have a cell phone that can text or search the internet? *

Yes

Not Sure

Do you have internet at home?

Yes

Maybe

Clear selection

Check all the items you would like to learn about during this conference: *

What local services will be impacted by new (proposed) legislation?

How will education be impacted by new (proposed) legislation?

How will sernior services be impacted by new (proposed) legislation?

What (if any) are changes in Medicare/Medicaid?

What (if any) are chages to benefits with Michigan Department of Health and Human Services?

The impact of eliminating Diversity, Equity and Inclusion funding.

Required

Would you like to receive our monthly newsletter to stay abreast of Black Impact Collaborative news and information? If so, please provide your email address below:

Please let us know if need any additional assistance,or community services.

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