Law Enforcement Torch Run Kick-Off * denotes a required field.TitleName* First Last Agency Head*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*-- Select County --AlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMercerMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSt. JohnsSt. LucieSanta RosaSarasotaSeminoleSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonRegion*View map to determine your Region.-- Select Region --12345678910Agency Type*-- Select Type --Sheriff’s OfficePolice DepartmentFL Department of CorrectionsFederal/State AgencyMilitaryOtherAgency Name*Examples: Lake Correctional Institution, Circuit 10, FBI-MiamiPhone*Direct line please (not agency number)Primary Email* Attendance*I will attend the kick-off on Friday, December 1 in OrlandoI will attend the kick-off on Friday, January 19 in TallahasseeI cannot attend, but will serve as Agency CoordinatorLodging*Special Olympics Florida will be making the reservations for hotel rooms and will pay for one night for individuals who are traveling more than 2 hours. We must have your request for a room by November 17 (Orlando) and by January 3 (Tallahassee).No Lodging RequiredThursday Night, November 30Thursday Night, January 18Willing to share a room?*Although we are not requiring attendees to share hotel rooms, we would greatly appreciate the gesture if you are willing to share with a friend or co-worker in order to keep our expenses to a minimum.Yes, please assign me a roommateYes, roommate request listed below:No thank you.N/AEnter your preferred roommate.EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.