EmailMeForm
Registration Application
Please complete this application to register for Unity Through Diversity the National Lesbian, Gay. Bisexual and Transgender People of Color Health Conference on October 4 - 7, 2018, 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):
Title:
Organization:
Web Address:
Address:
City:
State:
Zip:
Phone (with area code first):
Email:
Sex
Male
Female
Age
Under 20
20-25
26-30
31-40
41-50
50+
Sexual Orientation
Gay
Lesbian
Bisexual
Questioning
Heterosexual
Other
Race/Ethnicity
African American/Black
American Indian/Alaskan Native/Native American
Asian/Pacific Islander
Hispanic Latino(a)
Caucasian
Bi-or Multi-Racial
Other
Organization Information
Federally Funded Organization
State Funded Organization
State/Local Health Department
Community Planning Organization
Consultant Organization
Other
Gender Identity
Male
Female
Transgender MTF
Transgender FTM
Two-Spirited
Other
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:
Registration
Standard Registration *Must be Postmarked By: October 4, 2018 - Fee $375.00
Student Registration [ID Req] *Must be Postmarked By: October 4, 2018 - Fee $275
On-site Registrtion - $400.00a
Presenter Rate *Must be Postmarked By: October 4, 2018 - Fee $250.00
Daily Rate *Must be Postmarked By: October 4, 2018 - Fee $175.00
Sponsor (Free)
Active UTD Planning Committee Member
Additional Needs
Vegetarian
Wheelchair Accessibility
ASL
Interpreter needed? If yes, what
language(s)?
Other
Payment:
Please submit payment with registration. All registrations are non-refundable. Select payment type and submit with this registration form to:
Mail
In Our Own Voices, Inc.
245 Lark St.
Albany, NY 12210
Fax
518-432-4123
Payment Options:
American Express Credit Card
Mastercard/Visa Credit Card
Discover Credit Card
Creit Card
Payment Information
Account Number
Expiration Date
3-digit Security Code
Cardholder's name as it appears on card
Cardholder's signature
Total Amount Enclosed:
