Wild Out Wednesday KiKi & Dinner March 30, 2022

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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 23219There 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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NamePlease enter your name

First Name

Last Name

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Phone NumberPlease enter a valid phone number.

Area Code

Phone Number

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Have you registered for a past Wild Out Wednesday event before?

YESNO

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E-mailPlease enter a valid email address.

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Will you attend? Please confirm so that we can confirm the food orders

Yes

No

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Do you have any food allergies?If yes please list your allergies in the next section.

YESNO

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If you have food allergies, please list them below?List food allergies

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Do you require a vegetarian option? You must request this option now if you wish to reserve a vegetarian meal.

YESNO

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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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SignatureBy 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.

ClearSign with your finger or type your name to agree