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EMPOWER ROCKFORD

» How can I help?

Please fill out as completely as possible.
Name :
Address :
City :
State :	Zip :
Phone Number :
Fax number :
E-mail Address :
	Yes! Please add me to your email list. I want to stay informed of any activities.
	Yes! I would like a Yard Sign to put in my yard.

How would you like to help?
Delivering Yard Signs	Making phone calls
Sending cards or letters	Neighborhood campaigning
Helping out in our office	Fundraising
Other (note below)
Other:
Finally, when are you available?
Mornings \| Afternoons \| Evenings \| Weekends \| Anytime