Mid-Atlantic LGBTQA Conference - Individual Registration

NOTICE!

Completion of the registration process constitutes agreement and obligation to pay applicable registration fee.
Cancellation for any reason after Friday, October 25, 2024 will forfeit any refund.

Please see the Payment Methods & Policies section of the Conference page for additional information.

Registration Form:

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 Friday, November 3, 2023.

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 2023 Semester.

Name of Institution

Please enter the name of your College/University or Non-Profit Organization.

Name of Club/Organization

Please enter the name of your College/University sanctioned organization.

Payment Method *

Credit Card

Check

Checks must be postmarked by Friday, October 22, 2023.

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

	Yes	Undecided	No
Saturday morning presentation sessions	Saturday morning presentation sessions - Yes	Saturday morning presentation sessions - Undecided	Saturday morning presentation 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 presentation sessions	Saturday afternoon Keynote and presentation sessions - Yes	Saturday afternoon Keynote and presentation sessions - Undecided	Saturday afternoon Keynote and presentation 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.