National Training, March 2022

Contact information

Prefix

Name(Required)

First Last

Pronouns

Email(Required)

Phone(Required)

Emergency contact

Name(Required)

First Last

Phone(Required)

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 (Affiliate Rate)(Required)

Pay Now

Pay Later

Pay Now (Non Affiliate Rate)(Required)

Pay Now

Pay Later

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

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

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