Please complete this application to register for Unity Through Diversity the National Lesbian, Gay. Bisexual and Transgender People of Color Health Conference on October 12-15, 2016 at the Desmond Hotel and
Conference Center in Albany, New York. Type fields are marked with an asterisk ( * ). Please print clearly or type.
Name (first, last):
Phone (with area code first):
American Indian/Alaskan Native/Native American
Federally Funded Organization
State Funded Organization
State/Local Health Department
Community Planning Organization
Registration and Fees
Registration covers access to all workshops, group sessions, scheduled meals, exhibit hall, receptions, and other special events. It also includes all conference materials, including promotional gifts, brochures, and handouts. Select one:
Early Registration *Must be Postmarked By: August 1, 2016 - Fee $275.00
Standard Registration *Must be Postmarked By: October 12, 2016 - Fee $325.00
Student Registration [ID Req] *Must be Postmarked By: October 12, 2016 - Fee $267.00
On-site Registration - $350.00
Presenter Rate *Must be Postmarked By: October 12, 2016 - Fee $200.00
Daily Rate *Must be Postmarked By: October 12, 2016 - Fee $125.00
Check here if you are applying for a scholarship. Please fill out the Scholarship Application also.
Interpreter needed? If yes, what
Please submit payment with registration. All registrations are non-refundable. Select payment type and submit with this registration form to:
In Our Own Voices, Inc.
245 Lark St.
Albany, NY 12210
American Express Credit Card
Mastercard/Visa Credit Card
Discover Credit Card
Cardholder's name as it appears on card
Total Amount Enclosed:
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