2012 Student Day at the Capitol
Day at the Capitol Registration Form
March 7, 2012
First Name *
Last Name *
Email Address *
Date of Birth *
School or College You Represent
PHOTO RELEASE (optional): Please be advised that I hereby authorize Iowa Pride Network to reproduce my image, photographed or filmed for publicity and fundraising purposes.
Yes, By selecting "yes" in this box, you agree to the photo release.
Please enter the text from the image:
Iowa Pride Network
777 Third Street, Suite 312
Des Moines, Iowa 50309
Executive Director: 515-471-8062
Outreach Coordinator: 515-471-8063