Organization/Business:
	Site Facilitator: Mr. Mrs. Ms.	First Name:	Last Name:
	Title:
	Phone:
	Fax:
	E-mail:
	Address: (line 1)
	Address: (line 2)
	City:
	State:		Zip:
	Room Capacity:
Satellite Technician's Name:
Satellite Technician's E-mail:
Please add video conference site address. (No P.O. Boxes, Please!)
	Organization:
	Address: (line 1)
	Address: (line 2)
	City:
	State:		Zip:
Please provide general directions to the site that we can provide to participants. (This is a limited input field.)
After completing the registration form, choose one of the following options. 1.) Print out this page and fax or mail your response to: Safe Night USA Basic Training Site Registration 780 Regent Street Madison, WI 53715 FAX: 608-265-5039 2.) Submit your form electronically: