Community Diversity Conference 2024

How many people are you registering? *

Community Diversity Conference

First Name *

Last Name *

Street Address *

City *

State *

Postal Code *

Phone *

Email *

Organization

Job Title

Please note any dietary restrictions:

Do you require any Disability Accomodations?

How would you like your name to appear on your name tag? *

What are your preferred pronouns?

Conference Fee

Additional Donation/Sponsorship Amount:

Please enter the # of people for whom you are paying.

Conference Fee *

$115.00

Total for this participant

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *