Please join us for the inaugural Pennsylvania Department of Aging 2018 LGBTQ Aging Summit.

Dates/Times:
Tuesday, October 9, 2018 - 3:00pm - 5:15pm (reception 5:15pm - 6:30pm)


Wednesday, October 10, 2018 - 8:30am - 3:00pm

Location:
Sheraton Harrisburg Hershey Hotel
4650 Lindle Road
Harrisburg, PA  17111

After you complete the online registration form below, you'll automatically receive an email to confirm your registration.
 
When making payment, please make check payable to 'P4A' and mail to:
P4A, 525 South 29th Street, Harrisburg, PA  17104.
Kindly print 'LGBTQ Aging Summit' on the memo line of the check.


REGISTRATION FORM
:
* indicates required response

FIRST Name: (please capitalize the FIRST letter of your FIRST name)

Question Title

* 1. FIRST Name: (please capitalize the FIRST letter of your FIRST name)

LAST Name: (please capitalize the FIRST letter of your LAST name)

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* 2. LAST Name: (please capitalize the FIRST letter of your LAST name)

Email Address:

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* 3. Email Address:

BILLING ADDRESS:  If you're attending  the Summit on behalf of an organization and your agency is covering the cost of your attendance, please list your agency's name and billing address in the spaces provided below.  If you're not attending on behalf of an organization, please list your personal billing address in the spaces provided below.
Billing Address:

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* 4. Billing Address:

Registration Options & Fees:

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* 7. Registration Options & Fees:

Will you attend the evening RECEPTION beginning at 5:15pm on Tuesday, October 9th?

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* 8. Will you attend the evening RECEPTION beginning at 5:15pm on Tuesday, October 9th?

What brings you to the PDA LGBTQ Aging Summit? (check all that apply)

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* 9. What brings you to the PDA LGBTQ Aging Summit? (check all that apply)

Do you require ADA Accessibility?

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* 10. Do you require ADA Accessibility?

Special Dietary Needs:

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* 11. Special Dietary Needs:

In your opinion, what is the greatest barrier to inclusivity for LGBTQ older adults?

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* 12. In your opinion, what is the greatest barrier to inclusivity for LGBTQ older adults?

Please share any question you might have for our COMMUNITY panel:

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* 13. Please share any question you might have for our COMMUNITY panel:

Please share any question you might have for our PROVIDER panel:

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* 14. Please share any question you might have for our PROVIDER panel:

Please share any question you might have for our STATE panel:

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* 15. Please share any question you might have for our STATE panel:

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