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Models of Pride
Youth Track
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LGBTQ Resources
Parent & Professionals Institute
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Continuing Education
LGBTQ Resources
Power in Prevention
Info
Accessibility
MOP 30 Parent & Professional Registration
Rachel Birkenthal
2022-06-21T14:52:02-07:00
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)
Legal First Name
*
Legal Middle Name
Legal Last Name
*
Preferred Name (If you have one)
Email Address
*
Cell Phone
Birth Date
*
Current City of Residence
*
Current Zip Code
*
What is your profession?
Organization/Employer
Personal Gender Pronouns (she/her/he/him/they/zir/any)
*
(she/her/he/him/they/zir)
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
If other gender identity, please specify in box below:
Yes
No
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:
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
.
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