#submit_button {display:none; } For full functionality of this page it is necessary to enable Javascript.

STEP 1

Basic Contact Info

Complete the fields below. Please provide the full name and work email.

If you believe you have engaged with IYI in the past using a different name or email, please provide that information instead. You will have the opportunity to update your contact information on the next page.

First Name

Last Name

Organization

Organization Name

Please do not use abbreviations but the full name of your organization. If you are not associated with an Organization, input your "Last Name" Household. (e.g. Smith Household)

County (Office Location)

This is the Indiana county that is the main office location.

NOTE: If you receive an error message upon "Submit", please contact Scott Schoberg at sschoberg@iyi.org for further assistance. Please include a screenshot of the error message. There is no need to continue to re-Submit the form.

Contact Information