MOP 30 Youth Registration

Youth Registration

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 *

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

(she/her/he/him/they/zir)

If other race, please specify in box below:

If other gender identity, please specify in box below:

Yes No

If other sexual orientation, please specify in box below:

Choose up to three categories of workshops you would like to see at Models of Pride

Activism / Social Justice / Self-Empowerment

Arts & Culture / Education

Coming Out / Families / Spirituality / Faith

Education / Careers

Gender / Sexuality / Health

People of Color Community & Issues / Ally Community & Issues

Other (enter in box below)

If you would like a workshop category that is not listed, please specify in box below

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:

Emergency Contact Name

Emergency Contact Phone Number

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

Models of Pride 30 - Youth Registration 2022