IOAD Participant Registration Form - Mercer Council on Alcoholism and Drug Addiction

Participant Information

Name*

First Last

Email*

Phone*

Registration Type*

Individual Registration

Family/Group Registration

T-shirt Size*

Family/Group Information

Name of Family/Group*

If part of a family, please indicate the last name. If part of an agency, recovery group, or group of friends, please use a group name (i.e. “John Doe Memorial”)

Number of Family/Group Members*

Please indicate the total number of people that will be attending this event as part of your group (including yourself).

Name of Person #1*

First Last

Note: This is the primary point of contact for the family/group and is usually the name of the person who entered contact information on the previous page.

T-shirt Size of Person #1*

Name of Person #2*

First Last

T-shirt Size of Person #2*

Name of Person #3*

First Last

T-shirt Size of Person #3*

Name of Person #4*

First Last

T-shirt Size of Person #4*

Name of Person #5*

First Last

T-shirt Size of Person #5*

6+ Members in Family/Group

Please list the first and last names and t-shirt sizes for every additional member of the family/group besides the primary point of contact.

Overdose Awareness Memorial & Candlelight Vigil

Would you like to honor an individual or loved one who has been affected by overdose?

Yes

No

Name of Individual*

First Last

Include Photo?

Yes

No

Upload Photo*

Max. file size: 10 MB.

Brief Reflection of Individual*

Please use this section to share brief remarks about this individual that can be shared at the event and/or on digital platforms before or after the event.

Date of Birth

Date of Passing

Phone

This field is for validation purposes and should be left unchanged.