Youth 2023 – Models of Pride Registration

Models of Pride 2023 - Youth Registration

First Name *

Last Name *

Email Address *

Cell Phone

Birth Date *

Current City of Residence *

Current Zip Code *

Personal Gender Pronouns (she/her/he/him/they/zir/any) *

If other race, please specify in box below:

Other gender identity:

If other sexual orientation, please specify in box below:

For grades K-12, what is the name of your school?

If other, from whom/where?

We will do our best to provide assistance.

Do you need any of the following accommodations?

ASL interpreting (provide specifics in area below)

Alternative language translation (provide language in area below)

Accommodations details:

Dietary Restrictions

Vegan Gluten-Free

If any, what is your chaperon’s name?

Emergency Contact Name *

Emergency Contact Phone Number *

By clicking "Yes" I agree to the Models of Pride Release of Liability.

Models of Pride Release of Liability *

Yes