Training and Events Calendar Form

You may complete the online response form below to send electronically, or click here to print the pdf version and FAX to Health & Disability Advocates - 312-223-9518.  If you have any questions, please contact  events@makemedicarework.org or call 312-223-9600.

  

E-mail: *Required Field

Your Name: *Required Field

Date of Training or Event: *Required Field
 

Location: (Address including COUNTY*Required Field

 Target Geographical Area: *Required Field
 

Activity Type:  (training for professionals, 
consumer / family group event)
*Required Field

Start and End of Training/Event: *Required Field

Title of Training/Event: 

Lead Organization: *Required Field

Trainer/Speaker (s) & their organization: *Required Field

Subject Matter: *Required Field

Target Audience: *Required Field
 

Maximum Number of Attendees:

Contact Person and Phone Number:  *Required Field

RSVP or Registration required by what date?
If an RSVP or Registration is not required, please put NA in the box.

Public Transportation: 

Parking Directions and Costs: *Required Field
 

Wheelchair accessible?
Please indicate Yes or No  
 
*Required Field  

To request large print, Braille,
or other accommodation, contact: 
*Required Field

English or Other Language: 

Other Relevant Information:

          

 

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