Organizer Retreat, June 2023, Registration

Contact information

Prefix

Name(Required)

First Last

Pronouns

Email(Required)

Phone(Required)

Emergency contact

(Emergency Contact) Name(Required)

First Last

(Emergency Contact) Phone(Required)

(Emergency Contact) Email(Required)

Rooming and accommodations

Accessibility instructions/requests

Travel Plans, Arriving date and time. Departing date and time. Car or Airport. Which airport and Flight # – arrival time.(Required)

Why do you need my travel plans? In some cases, we may be able to provide transportation but not guaranteed. Knowing your travel plans will help us coordinate transportation.

Payment options

Pay Now (Affiliate Rate)(Required)

Pay Now

Pay Later

Name of your affiliate organization(Required)

Payments are due at the beginning of training, payment options will be available on your confirmation email. Questions about payment contact Regina Lewis at 312-357-2639

Total

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Credit Card(Required)

Card Details

Cardholder Name