2020 Catalyst to the Capitol Partnership Application
Join our 2020 Catalyst to the Capitol Partnership!

Partners are asked to pay $350 per seat to attend Dade Days in Tallahassee with Catalyst Miami. Seats will be reserved on a first-come, first-served basis.

The trip includes transportation, lodging, access to our scheduled visits, as well as trainings and activities. Meals are included when attending Catalyst Miami events. Partners' logos will also be added to our materials (optional).

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Name *
Email *
Organization Name *
Street Address
City
Zip Code
Phone Number *
Have you ever participated in any Catalyst Miami Dade Days trip to Tallahassee?  If so, when? *
What policy issues is your organization interested in (i.e. healthcare, Medicaid expansion, education, minimum change, criminal justice reform, climate change, environmental, etc.)? *
Are you supporting/opposing any bills during this session? If so, which? *
Have you participated in policy advocacy and/or direct actions in the past?(i.e. town halls meetings, canvassing, rally, marches, calls to legislators, letters to legislators, etc.) *
Do you have any media contacts and/or partners attending Tallahassee Dade-days? If so, who? *
Do you have connections with policy makers that we can meet with during Dade-days? If so, who? *
Please use the area below to describe any specific accommodations that you will require in order to take part in this trip. Be advised that this is a physically demanding trip, which includes extended periods of moving/standing and the use of steps in order to enter or exit the charter bus used for transportation.
Do you have any allergies and medical conditions we should know about? (i.e. allergies: food, insects, medicine; medical conditions: diabetes, asthma, etc.)
Emergency Contact Information
Primary Emergency Contact  Name:
Relationship to Contact:
Daytime Phone / Evening Phone
Email Address:
Secondary Emergency Contact Name:
Relationship to Contact
Daytime Phone/ Evening Phone
Email Address:
I give my permission for this information to be shared with program funders for monitoring and evaluation and funding purposes. (Sign below) *
I hereby authorize and give consent to Catalyst Miami and program funders to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotaped recordings of me for educational, research, documentary, marketing, and public relations purposes. (Sign Below) *
In consideration for being allowed to participate in this Activity, I release from liability and waive my right to sue the Catalyst Miami, Inc., their employees, officers, volunteers and agents from any and all claims, including claims of their negligence, resulting in any physical injury, illness (including death) or economic loss I may suffer or which may result from my participation in this Activity, travel to and from the Activity or any events incidental to this Activity. (sign below) *
Signature *
Today's Date *
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