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2. First Name*
3. Last Name*
5. Address1
7. Address2
9. City*
10. State*
11. Zip*
13. Cell or Home Phone*
15. E-mail*
17. Place of Employment and Title*
19. Why do you want to participate in Dothan 101?*
21. Length of residence in Dothan*
23. Are you an active member of a neighborhood association?*
    -- Select One --YesNo
25. If yes, which one?
27. If you hold a neighborhood association position, what is your title?
29. Would you be willing to participate in a neighborhood communication program to facilitate communication between your neighborhood and the City of Dothan?
    -- Select One --YesNo
31. Do you require any specific accommodations for a physical disability or dietary allergy?*
    -- Select One --YesNo
33. If yes, please explain.
35. I agree to sign a Hold Harmless, Release and Indemnification Agreement.*
    -- Select One --YesNo
37. Men's Golf Shirt Size
    -- Select One --SmallMediumLargeXLXXLXXXL
39. By checking "I agree" you certify that the information you have given is true and correct to the best of your knowledge. You agree to abide by all the rules and regulations of the City of Dothan as a participant of Dothan 101. You understand that any misrepresentation on the application or misconduct will result in you being removed from the program.*

    1. I agree
    2. I disagree
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41. 1. Receive an email copy of this form.
42. Email address

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43. Submit

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