AOTA Capitol Hill Day Registration Form
AOTA Capitol Hill Day
Registration Form
Date of Hill Day You Will Attend: __________________________________
I am an: __ OT __ OTA __ OT Student __ OTA Student
AOTA ID#: ___________________________________ (if available)
Full Name: ________________________________________________________
Home Address: ____________________________________________________
__________________________________________________________________
City: ________________________________ State: _________ Zip: __________
Employer: ________________________________________________________
Employer City/State/Zip: ____________________________________________
If a Student, School Attending: _______________________________________
Phone Numbers: Indicate best one to reach you during the day by checking it.
__ Home Phone: _____________________________________________________
__ Work Phone: _____________________________________________________
__ Cell Phone: _______________________________________________________
E-Mail Addresses:
Home: ___________________________________________________________
Work: ___________________________________________________________
Alternate: _________________________________________________________
Members of Congress You Intend to Schedule Appointments With:
House of Reps: ____________________________________________________
U.S. Senate: ______________________________________________________
_________________________________________________________________