ENCOUNTER Charlotte Registration - April 24th and 25th, 2024 Survey

1.Name(Required.)

First Name

Last Name

Prefer to be called

2.Year of birth (enter 4-digit birth year; for example, 1976)(Required.)

3.Gender(Required.)

4.Race/Ethnicity(Required.)

5.Headshot

Upload your photo here.

No file chosen

6.Current Employer(Required.)

7.Occupation/Title(Required.)

8.Home Contact Information(Required.)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell Phone Number

9.Preferred Contact Information (if different from above)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

10.Emergency Medical Contact Person(Required.)

Name

Relationship to you

Mobile Phone Number

11.To ensure accurate application of your payment, please note below any other name or entity that may be associated with your ENCOUNTER tuition. If none, please put N/A.(Required.)

12.I would be interested in learning about scholarship opportunities for ENCOUNTER.(Required.)

Yes.

No.

13.How did you hear about ENCOUNTER Charlotte?(Required.)

14.How long have you lived Charlotte?(Required.)

15.Where did you previously live (if anywhere)?(Required.)

16.Why did you relocate to Charlotte (if applicable)?(Required.)

17.What are the top three Charlotte leadership areas you would like to know about?(Required.)

1st Leadership Area

2nd Leadership Area

3rd Leadership Area

18.What are your current (or previous) volunteer interests?(Required.)

1st Volunteer Interest

2nd Volunteer Interest

3rd Volunteer Interest

19.Do you have any food allergies or dietary restrictions?(Required.)

No.

Yes (please specify below)

Details of your allergy or restriction: