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National Training, August 2023
Contact information
Prefix
Name
(Required)
First
Last
Pronouns
Email
(Required)
Phone
(Required)
Emergency contact
Emergency Contact Name
(Required)
First
Last
Emergency Contact Email
(Required)
Emergency Contact Phone
(Required)
Rooming and accommodations
Preferred roomate
Food restrictions or requirements
Accessibility instructions/requests
Travel Plans
I will be flying in for this training
I will be driving myself or carpooling in for this training.
Photo/Video Release
(Required)
I agree to the following statement.
I hereby grant permission to Gamaliel and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Gamaliel and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or presentation, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation A acknowledge that I am over 18 years of age.
Signature
(Required)
Payment options
Your Gamaliel Affiliation
(Required)
Gamaliel Affiliate
Not A Gamaliel Affiliate
Name of your affiliate organization
(Required)
Tell us about your organization
(Required)
Pay Now (Affiliate Rate $850)
(Required)
Pay Now
Pay Later
Pay Now (Non Affiliate Rate $1,700)
(Required)
Pay Now
Pay Later
Single Room
Yes I would like a single room.
By default all rooms are doubles meaning you are with a roommate. If you would like a single room add +350 to the registration rate. Deadline to register for a single room is August 5th.
Single Room – Non Affiliate Rate
Yes I would like a single room.
By default all rooms are doubles meaning you are with a roommate. If you would like a single room add +700 to the registration rate. Deadline to register for a single room is August 5th.
Payments are due at the beginning of training, payment options will be available on your confirmation email. Questions about payment contact Regina Mahone at 312-357-2639 ext. 102
Total
Credit Card
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
Month
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
Security Code
Cardholder Name
Billing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Credit Card
(Required)
Card Details
Cardholder Name
