Mid-Atlantic LGBTQA Conference - Group Member Registration

Please complete the form below for each member of the group planning to attend the conference.

Registration Form:

Group Relationship *

First Name *

Please enter your name as you would like it to appear on your name tag.

Last Name *

Please enter your name as you would like it to appear on your name tag.

Age *

Please indicate the age you will be on Saturday, November 5, 2022.

Email Address *

Please enter your email address. Only one registration permitted per email address. If you need to revise your registration, please contact MidAtlanticLGBTQA@bloomu.edu.

Academic Status *

Please select your academic standing as of the Fall 2022 Semester.

Please indicate your plans to attend each of the following: *

	Yes	Undecided	No
Saturday morning sessions	Saturday morning sessions - Yes	Saturday morning sessions - Undecided	Saturday morning sessions - No
Saturday lunch at Scranton Commons Dining Hall	Saturday lunch at Scranton Commons Dining Hall - Yes	Saturday lunch at Scranton Commons Dining Hall - Undecided	Saturday lunch at Scranton Commons Dining Hall - No
Saturday afternoon Keynote and sessions	Saturday afternoon Keynote and sessions - Yes	Saturday afternoon Keynote and sessions - Undecided	Saturday afternoon Keynote and sessions - No
Saturday evening Drag Show	Saturday evening Drag Show - Yes	Saturday evening Drag Show - Undecided	Saturday evening Drag Show - No

Dietary Needs

Vegetarian

Vegan

Food Allergies (Please provide details below)

Physical Needs

Wheelchair Accessibility

Van Parking

Hearing Impairment

Visual Impairment

Additional Comments

Please describe any special dietary or physical needs.