March 9, 2011-Illinois Muslim ACTION! Day Register Form

Your investment of one day will plant seeds of citizen advocacy for generations!

Name:	required.
Address:	required.
City:	required.
State:	required.
Zip:	required.Invalid format.
Phone:	required.Invalid format.
E-mail Address:	required.Invalid format.

	Is this your first IMAD experience?
	YES NO Please make a selection.

	What masjid would be your preferred training and pick-up location
	required.

	Would you like to be a bus captain?
	YES NO Please make a selection.

Please contribute $15 per person to help cover costs for lunch, transportation and info packets. Please click the link in next window to pay through credit card or paypal account. Thanks