UCLA Day in DC

Monday, May 16th to Wednesday, May 18th


Delegate Registration
*First Name:
*Last Name:
*Home Street Address:
*City, State, Zip:    
Home Phone:
*Cell Phone:
Social Media Handle:
*Emergency Contact Name:
*Emergency Contact Phone Number:
Business Title:
Business Name:
Business Street Address:
Business City, State, Zip:    
Business Phone:
Fax:
*Preferred E-mail:
Preferred Mailing: Home Business
Current UCLA Student Yes No
UCLA Alumnus: Yes No
UCLA Degree Year:
Major:
I was an AAP student
  Number of years: 
I received Pell Grants
  Number of years: 
Affiliation: Donor
Faculty
Friend
Parent
Retiree
Staff
Student
Optional
Party Affiliation:
United States Representative:
Find your legislator:
http://advocacy.ucla.edu/impact/336-2/

Meal Preferences (Check all that apply)

Vegetarian
Vegan
Food Allergies (if yes, please explain)
 

Notes/Special Instructions

Please include any special accommodations needed such as handicap accessibility.
I would like to be added to the UCLA Advocacy email list for
notifications on upcoming events and volunteer opportunities.

* Required fields are marked in Red

          

For questions or more information please contact
Randall Avila at ravila@support.ucla.edu or (310) 794-6817.


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