Regionals Registration

Name *

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Last

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Email *

Registration Type *

Address *

City *

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Phone *

Preferred Name for Badge *

What is your Major? *

In accordance with the American with Disabilities Act, do you have any special needs? (If yes, you will be contacted) *

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Do you have any special dietary needs? *

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Please indicate special dietary need *

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If "other," special dietary need, please describe *

Emergency contact name: *

Emergency contact number: *

Do you want your name displayed on the website as a conference attendee? *

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