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Presents: "WILD OUT WEDNESDAYS" Ki Ki Edition
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Join Minority Health Consortium "Wild Out Wednesdays Ki Ki Edition & Dinner on March 30, 022, 6:00 pm at The Minority Health Community Engagement Center located at 206 East Clay Street Suite, B Richmond, VA 23219
There is limited parking in the rear of the building by entering from the 3rd Street side alley way. On street parking is available. There will be drawings for door prizes during the event.
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2
Name
Please enter your name
First Name
Last Name
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3
Phone Number
Please enter a valid phone number.
Area Code
Phone Number
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4
Have you registered for a past Wild Out Wednesday event before?
YES
NO
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5
E-mail
Please enter a valid email address.
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6
Will you attend?
Please confirm so that we can confirm the food orders
Yes
No
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7
Do you have any food allergies?
If yes please list your allergies in the next section.
YES
NO
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8
If you have food allergies, please list them below?
List food allergies
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9
Do you require a vegetarian option?
You must request this option now if you wish to reserve a vegetarian meal.
YES
NO
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10
Are you vaccinated against the COVID-19 virus?
I have received 1st Dose.
I have received 2nd Dose
I have received the Booster Dose
I have received a 4th Dose
I have not been vaccinated
I decline to disclose my vaccine status
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11
Signature
By placing your signature, you understand that due to the nature of this event that you: 1. Should not photograph anyone at this event without their permission 2. Not disclose the status or breach the confidentiality of the persons who may attend this event. 3. You agree not to consume or use substances such as alcohol, marijuana, or controlled substances on the premises 4. I understand that it is my responsibility to exercise COVID-19 precautions such as handwashing, using sanitizer, wearing a mask, and maintaining social distancing.
Clear
Sign with your finger or type your name to agree
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