MOP 30 Parent & Professional Registration – Models of Pride

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MOP 30 Parent & Professional RegistrationRachel Birkenthal2022-06-21T14:52:02-07:00

Models of Pride 30 - Parent & Professional Registration 2022

Parents & Professionals Registration

Are you registering as a Parent or a Professional? *

Parent (or other family/adult supporter)

Professional (i.e. educator, therapist, etc)

First Name *

Last Name must match that of your COVID-19 Vaccination Card or Negative PCR Test

Last Name *

Email Address *

Cell Phone

Birth Date *

Current City of Residence *

Current Zip Code *

What is your profession?

Organization/Employer

I would like to receive a certificate request

I would like to receive a certificate of attendance please

Are you planning to obtain California Continuing Education hours? Credits are available for LAUSD staff, LMFT, LCSW, LPCC, and LEP licensures. A non-refundable $25 fee will be due below to complete your registration. *

Yes No

If you are planning to obtain California Continuing Education hours, which is your licensure level?

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

Race *

Black/African American

Latinx / Hispanic

Asian Pacific Islander

Caucasian (Non-Hispanic)

Native American

Multi Racial

Other

If other race, please specify in box below:

Gender Identity *

Cisgender Woman

Cisgender Man

Transgender Man

Transgender Woman

Gender Queer

Nonbinary

Other

Other gender identity:

Sexual Orientation *

Pansexual

Queer

Bisexual

Lesbian

Gay

Straight

Other

If other sexual orientation, please specify in box below:

How did you hear about Models of Pride? (select all that apply) *

Previously Participated

Family told me about it

Friends told me about it

Through Work (Co-Worker, Supervisor, students, etc.)

Facebook

Instagram

Other (fill-in option)

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:

T-Shirt Size

XS S M L XL 2XL I don't want a T-Shirt

Dietary Restrictions

Vegan

Gluten-Free

COVID-19 Proof of Vaccination *

I will bring proof of my COVID-19 vaccination or a negative test.

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

Models of Pride Release of Liability *

Yes

Release and Waiver of Liability.

Optional Event Fees

Sponsor a youth! Your donation of $35.00 covers the cost of one youth to attend Models of Pride. Every dollar counts so if you would like to donate more, please do so! Your donation helps keep this amazing event free for both Youth and Parents & Professionals.

Sponsorship Donation ($)

CA Continuing Education Fee

$25

Total

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