National Training, June 2022 – Gamaliel Network

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

Preferred roomate

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

Your Gamaliel Affiliation(Required)

Gamaliel Affiliate

Not A Gamaliel Affiliate

Name of your affiliate organization(Required)

Tell us about your organization(Required)

Pay Now, standard double occupancy room (Affiliate Rate)(Required)

Pay Now ($750.00)

Pay Later ($750.00)

Options

Single room + 200

Pay Now, standard double occupancy room (Non Affiliate Rate)(Required)

Pay Now

Pay Later

Options

Single room + 400

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

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Your card will be processed securely and immediately.

Billing Address(Required)

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

Credit Card(Required)

Card Details

Cardholder Name