Regional Council Enrollment Form

First Name *

Last Name *

Title *

Municipality *

Email Address *

Business Phone *

Cell Phone

Please use this map to determine in which region you are located.

What region are you in? *

Please answer the following: *

	Yes	No
Will your council/board provide you with a resolution confirming their approval for you serving on the regional council?	Yes	No
Are you willing to participate in Legislative Activities in your area and at the State Capitol?	Yes	No
Are you willing to travel to meetings at least four times a year and possibly more if you’re selected to serve on any sub committees?	Yes	No
Are you willing to serve in a leadership role?	Yes	No