Registration 5/21/17

Registration Form for Coordination

A Civic People of Baton Rouge
Establish We the Civic People of the United States

for June 21, 2017

Name:  ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________________

Address:  ­­­­­­­­­­­­­­­­­­________________________________________________________________

E-Mail Address:   _______________________   Affiliation: _________

Phone numbers cell:   _____________________     Land phone: ____________

If Student/Faculty, circle:   Student    Faculty    School______________   

How did you learn about the meeting? (circle any):  Blog     Radio   Friend  Flyer            Invitation        Newspaper      Library       Presenter

What motivates you to participate? ­­­­­___________________________________­­­­­­­­­­­­­­­­­_________________________

How would you paraphrase the preamble to the US Constitution?

Which of the nine civic goals would you consider/discuss--in a future meeting to consider needs for 2017? (circle one): establish justice          form a more perfect Union         insure domestic Tranquility   provide for the common defense       promote the general Welfare            secure the Blessings of Liberty to ourselves             secure the Blessings of Liberty to our Posterity    refine the Constitution         promote domestic goodwill

Concerns regarding civic safety and security:  ________________________________________

 ______________________________________________________________

Skills and resources you may offer:  ­­­____________________________________________

 ______________________________________________________________

Please scan, complete as much as you wish and email to philrbeaver@gmail.com , or mail to

Phil Beaver, 1624 Leycester Drive, Baton Rouge, LA 70808