Wayne Tomorrow! is gathering information to update our contact list and to help gauge the actual reach of the network. Please complete the online form below.

Personal Information

First Name:*

Last Name:*

Home Address: (Street)*

Home Address: (City, State)*

Home/Cell Phone Number:*

Email Address:*

Organization or Business Address

Organization or Business Phone Number:

Occupation:

If you are representing an organization or business, do you have a designee to attend Community Impact Network (CIN) meetings when you cannot?

Yes

No

If yes, list name and email:

Organization Involvement Information

Please indicate your current Wayne Tomorrow! involvement.

Agriculture Task Force Community Hubs Task Force Community Impact Network Health & Wellness Taks Force Housing Task Force

Technology Transportion Workforce Email Updates Other

Are you currently serving on other Boards, Commissions, or Committees?*

Yes

No

If yes, which:

Please List Other Areas of Special Interest

Thank you for taking the time to share this information with us.