Uncle Julio's Rio Grande Protest Registration Form

Name * First Last

Email *

Year of Birth *

Street Address 1

Street Address 2

City

State *

Zip Code

How would you like to assist in our campaign to make Uncle Julio's Rio Grande restaurants stop serving frog legs? *

I will take part in the protests I would like to lead a protest I can attend the protest, and also help organize and promote it. I cannot attend the protest, but I can help organize and promote it.

Check all that apply

At which restaurant location would you like to protest (or otherwise assist)? *

Please check one TEXAS: Dallas (4125 Lemmon Ave.) TEXAS: North Dallas (16150 Dallas Parkway) TEXAS: Fort Worth (5301 Camp Bowie Blvd.) TEXAS: Grapevine (1301 William D. Tate Ave.) TEXAS: Allen (Northbound 75 traffic exit Exchange Parkway 190 East Stacy Road) VIRGINIA: Arlington (Ballston - 4301 N. Fairfax Dr.) VIRGINIA: Fairfax (4251 Fairfax Corner Ave.) VIRGINIA: Reston (Reston Town Center - 1827 Library St.) MARYLAND: Bethesda (4870 Bethesda Ave.) MARYLAND: Gaithersburg (231 Rio Boulevard) ILLINOIS: Lombard (2360 Fountain Square Drive) ILLINOIS: Chicago (855 W North Ave) GEORGIA: Atlanta (1860 Peachtree Rd NW) GEORGIA: Atlanta (Sandy Springs - Perimeter Area - 1140 Hammond Drive NE) FLORIDA: Boca Raton (449 Plaza Real)

If you have previous protest experience, or any relevant experience, please describe it here.

I agree to allow SAVE THE FROGS! to use any photos or videos from the protests that i may appear in (note: SAVE THE FROGS! will never provide your name to the public). *

YES NO

If you have any suggestions, please state them here. Thanks!

Wufoo