Exit this survey 2012 Summit RegistrationLast day to register online is July 27th, 2012After that, registration can be done at the door, space permitting. Question Title * 1. Contact Information Name Title Organization Address City State Zip Telephone Email Question Title * 2. I am (check all that apply): Under the age of 25 Staff member of a community based organization A staff member of a foundation or funding organization A government official A health care provider An activist/advocate A concerned Individual Other, please specify Question Title * 3. The cost to attend the summit will be $99 with onsite registration being $150. Would you like to: Pay online (link at end of registration) Pay via check (information at end of registration) Pay at the door Question Title * 4. Do you have any dietary restrictions? Vegan Vegetarian Other, please explain: Submit
