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Our Power, Our Vote, Our City, Memphis Resident Registration Form
Step
1
of
6
16%
Prefix
Name
(Required)
First
Last
Pronouns
Preferred Email
(Required)
Preferred Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Gamaliel Affiliate Name
(Required)
Emergency Contact Information
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Emergency Contact Email
(Required)
Will you be traveling to Memphis by car?
(Required)
Yes
No
If answered yes to the previous question, are you willing to assist with transportation for other participants to key venues while in memphis?
(Required)
Yes
Maybe
No
Including yourself how many people can you transport.
(Required)
1 = yourself
2
3
4
5
6
7
8
9
10
Dietary restrictions
Dietary restrictions: ie: vegetarian, allergies etc.
(Required)
By registering for and participating in Boots on the Ground: Gamaliel in Memphis,
I hereby grant Gamaliel the right and permission to photograph, video, and/or record me and to use the photograph, video, and/or recording for promotional purposes. I waive any right to inspect or approve the use of the photograph, video, and/or recording, and acknowledge and agree that the rights granted to this release are without compensation of any kind.
Signature
(Required)
Memphis area residents, full weekend event
(Required)
Price:
Full event includes meals and training.
Total Due
Payment selection
(Required)
Pay Now
Pay Later - Payment is due before the start of the event.
Billing Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Credit Card
(Required)
Card Details
Cardholder Name
