Portland Black Pride LGBTQ Registration

Portland Black Pride LGBTQ Summitt

Thank you for registering for the 2012 Portland Black Pride LGBTQA Summit. This year’s summit will take place at Portland Community College Cascade Campus on June 9, 2012 from 11:00am-4:30pm. Registration is free for the summit, but you must register to make sure we have enough food for all participants.

Our theme this year is "Together We Can" - an attempt to explore our diversities & multiple identities and the ways we can stand in solidarity as we come together as a community.

If you have any questions about the summit or your registration, please contact Maurice Evans at mevans@cascadeaids.org or by phone at 503-847-7035.

You can also check out more information at Portland Black Pride Facebook page

A huge thank you to this years sponsors (so far):
PFLAG Portland/PFLAG Black Chapter,Multnomah County- HIV/AIDS Community Prevention Program,Cascade AIDS Project
PCC Cascade Gay Student Association,
Basic Rights Oregon,Crossover.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your age?

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* 4. What city do you live in?

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* 5. Are currently a student? If yes what School? (If not currently enrolled type NA)

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* 6. Do you attend/volunteer/work with any organizations?

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* 7. What is your email address? (We don't share this information)

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* 8. What is the best phone number to reach you at? (Type NA if you don't have one)

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* 9. RACE / ETHNICITY: (You may check more than one.)

Black / African-American

African

Multi racial

Hispanic or Latino/a

Native Hawaiian or Other Pacific-Islander

Native American/Alaskan Native

Asian/Pacific Islander

White / Caucasian

Other (please specify)

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* 10. What gender do you identify as?

Male

Female

Trans (MTF)

Trans (FTM)

Gender Queer

Other (please specify)

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* 11. Do you have any dietary restrictions?

None

Vegetarian

Vegan

Gluten-Free

Other Allergies (please list)

Other (please specify)

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* 12. Do you have any medical/accessibility needs? (Allergies, wheelchair access, interpreter etc?)

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* 13. Please check all that apply below:

I am interested in donating materials to Portland Black Pride LGBTQ Summit

I am interested in donating money to the Portland Black Pride LGBTQ Summit sponsorship fund

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* 14. Conduct & Liability Agreement
I hereby waive all claims arising from my participation, and acknowledge that Cascade AIDS Project and Portland Community Collgee do not have any additional obligations in this regard, nor will they be held liable for damages to self or personal property.

In order to minimize the risks involved I, as a participant, agree to follow the rules and procedures of the Portland Black Pride LGBTQ Summit. I will not possess or consume alcohol or other drugs (other than those prescribed by my doctor, in prescribed amounts) immediately before or during the Portland Black Pride LGBTQ Summit, nor will I engage in disruptive or unsafe behavior that could endanger myself, staff, volunteers or other participants.
By clicking YES, I agree to the statement above and will attend the Portland Black Pride LGBTQ Summit at Portland Community College June 9th, 2012.

Yes